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Full text of "Medicare & you"

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2001 



This handbook has important information about: 

•Your Medicare benefits. 

•Your Medicare plan choices. 

• Medicare health plans in your area. 

•Where to call for help. 

How do you find what you need? See page 3. 
Please keep this handbook for future reference. 



HEALTH CARE FINANCING ADMINISTRATION 

The Federal Medicare Agency 



SECTION 1: MEDICARE BASICS 

Welcome to Medicare & You! 

This handbook has important Medicare information. Please keep it with your important 
papers so you can find it if you need it. Page 3 tells you how to find what you need in 
this handbook. You can get a quick look at Medicare on page 4. 

This handbook is good (valid) from January 1, 2001 through December 31, 2001. Use it 
in place of any older version you have now. You will get a new handbook every fall. 

Fall is a good time to think about health coverage for the coming year. Make sure you 
know what coverage you have now. Find out if you have other options. Get the facts you 
need to make the best choice for you. 

We want you to know: 

y You may have choices in how you get your Medicare health coverage (see page 13). 

y Medicare doesn't pay for all of your health care. You may be able to get help paying 
the costs that Medicare doesn't pay (see page 1 1). 

/ You can call 1-800-MEDICARE (1-800-633-4227, TTY/TDD: 1-877-486-2048 for 
the hearing and speech impaired) with questions about Medicare (see page 68). 
Medicare information is also at www.medicare.gov on the Internet. 

y You may need details about Medicare topics that you can't find in this handbook. 
Medicare has a series of more detailed booklets on some common topics (see 
page 66). 

y If you get help from family or friends with your health care choices, this handbook 
might help them. They can call 1-800-MEDICARE (1-800-633-4227) to get their 
own copy. 



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Donna E. Shalala 
Secretary, Health and 
Human Services 



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Nancy-Ann Min DeParle 
Administrator, Health Care 
Financing Administration 



1-800-MEDICARE (1-800-633-4227) 



v»* V^K2 What's A/EI/I/ in Medicare 



This handbook has new information for 2001 : 

• More help from l-800-MEDICARE (1-800-633-4227, TTY/TDD: 1-877-486-2048 for the 
hearing and speech impaired), see page 68. 

• A new Medicare health plan option - Private Fee-for-Service plans, see page 17. 

• Comparing Medigap plans on the Internet, see page 60. 

• Information about Medicare health plan choices. This includes how to get cost, extra benefits, 
quality, and disenrollment information for health plans in your area, see page 22. 

• More free Medicare booklets you can order, see page 66. 

If you have Employer or Union Health Coverage: 

Call your employer or union before you make any changes to your health coverage. 
See page 12 for important information. 

If you are a Railroad Retiree: Call your local Railroad Retirement Board office for 
answers to Medicare questions. You can find your local office by calling 1-800-808-0772. 
More information about Medicare for Railroad Retirees is on the Internet at www.rrb.gov. 



Sharing Medicare & You: 

Households with up to four people with Medicare will get one handbook to share. This will 
help save Medicare money. The other people with Medicare in these households will get a 
postcard. It will tell them how to get an extra handbook if they need it. If your household 
gets more than one handbook and you want to share one copy in the future, or, if you don't 
want to get this handbook next year, call and tell a customer service representative at 
1-800-MEDICARE (1-800-633-4227, TTY/TDD: 1-877-486-2048 for the hearing and 
speech impaired). Have your red, white, and blue Medicare card with you when you call. 




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If your address changes: 

Call the Social Security Administration at 1-800-772-1213. 



Turn to page 2 for the Table of Contents. 

Medicare & You 2001 explains the Medicare program. It is not a legal document. The official Medicare 
program provisions are contained in the relevant laws, regulations, and rulings. 

www.medicare.gov 1 



TABLE OF CONTENTS 

SECTION - TOPIC PAGE(S) 

What's New in Medicare! 1 

How to find what you need in this handbook 3 

Section 1 Medicare Basics -A Quick Look At Medicare 4 

Section 2 Your Medicare Benefits 

What is Part A (Hospital Insurance) 5 

Part A Coverage Chart 6 

What is Part B (Medical Insurance) 7 

Part B Coverage Charts (including Preventive Services) 8-9 

What is not paid for by Medicare 10 

Help to Pay Health Care Costs (Medicaid Programs) 1 1 

Section 3 Medicare Health Plans 

Other Kinds of Health Insurance You Might Have 12 

Medicare health plan choices 13 

What to think about when choosing a health plan 13 

Original Medicare Plan 14-15 

Medigap Policies (Supplement Insurance) 15 

Medicare Managed Care Plans 16-22 

Private Fee-for-Service Plans 17-21 

Employer or Union Coverage 22 

For More Health Plan Information 22 

Section 4 Where to Call for Help (Phone Numbers For Each State) 23-44 

Section 5 Your Medicare Rights and Protections 45-51 

Section 6 Frequently Asked Medicare Questions and Answers 52-65 

Section 7 For More Information 

Free Medicare and Related Booklets 66 

How to use 1-800-MEDICARE 68 

Section 8 Definitions of Important Terms 69-71 

Section 9 Index (An alphabetical list of what is in this handbook) 72-73 



1-800-MEDICARE (1-800-633-4227) 



How to find what you need in this handbook: 

Do you: Look on page(s): 



Want to look for a specific topic? 



Want to sign up for Medicare? 

Want basic Medicare information? 

Want to know what Medicare covers, 
including preventive services? 

Want to know about your Medicare health 
plan choices? 

Want to know how to join or leave a 
Medicare health plan? 

Want to compare Medicare health plans? 



72 - 73. Index: See the Index for an alphabetical 
list of everything in this handbook and the page(s) 
where you will find the information you need. 

5 and 7 

4 

5-10 



12-22 



19-20 



22 



Need help paying your health care costs? 1 1 (low income help) 

15 (Medigap, or Medicare Supplement Insurance) 

Want to know about your Medicare rights? 45 - 5 1 



Have employer or union coverage? 

Need information about home health, 
hospice, or skilled nursing care? 



12 and 53 (Q5) 

5-8 



Need information about mental health care? 63 (Q25) 



Want to call someone for help? 



23-44 



Want a booklet about a specific Medicare 66 - 67 

topic? 



Want to know what a word in this book 



69 - 7 1 (words in red are defined) 



means 



> 



wvvw.medicare.gov 



SECTION 1: MEDICARE BASICS 



A Quick Look At Medicare 



Medicare 
is a health 
insurance 
program 
for: 



People age 65 or older. 

Some people with disabilities under age 65. 

People with End-Stage Renal Disease (permanent kidney failure 
requiring dialysis or a transplant). 



Medicare Has Two Parts 



Part A (Hospital Insurance, see page 5.) 
Most people do not have to pay for Part A. 



Part B (Medical Insurance, see page 7.) 
Most people pay monthly for Part B. 



You may have 
choices in 
how you get 
your health 
care. 



— The Original Medicare Plan - For more information, see page 14. 

— Medicare Managed Care Plans (like HMOs) - For more 
information, see page 16. 

NEW Medicare Private Fee-for-Service Plans - For more 
information, see page 17. 



1-800-MEDICARE (1-800-633-4227) 



SECTION 2: YOUR MEDICARE BENEFITS 



What is Medicare 
Part A? 



Part A (Hospital Insurance) 

Helps Pay For: Care in hospitals as an inpatient, critical access 
hospitals* skilled nursing facilities, hospice care, and some 
home health care. See page 6. 



Do you need a new 
Medicare card? Call the 
Social Security 
Administration toll-free at 
1-800-772-1213 or call 
your local Social Security 
office. 



Cost: Most people get Part A automatically when they turn 
age 65. They do not have to pay a monthly payment called a 
premium for Part A because they or a spouse paid Medicare 
taxes while they were working. 

If you (or your spouse) did not pay Medicare taxes while you 
worked and you are age 65 or older, you still may be able to 
buy Part A. If you are not sure if you have Part A, look on your 
red, white, and blue Medicare card (see sample card below). It 
will show "Hospital Part A" on the lower left corner of the 
card. You can also call the Social Security Administration toll- 
free at 1-800-772-1213 or call your local Social Security office 
for more information about buying Part A. If you get benefits 
from the Railroad Retirement Board, call your local RRB 
office or 1-800-808-0772. 




HEALTH CARE FINANCING ADMINISTRATION 
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For More Information: 

Call your Fiscal Intermediary about Part A bills and services 
(see pages 29A-31). 

^Critical access hospitals (CAHs) are small facilities that 
give limited outpatient and inpatient services to people in 
rural areas. If you have questions about CAHs, call your 
HCFA Regional Office (see page 44), or your Fiscal 
Intermediary (see pages 29A-3 1 ). 

www.medicare.gov 5 



SECTION 2: YOUR MEDICARE BENEFITS 



Medicare Part A (Hospital Insurance) What YOU Pay in 2000* in the Original 
Helps Pay For: Medicare Plan 



Hospital Stays: Semiprivate room, meals, general 
nursing, and other hospital services and supplies (this 
includes care in critical access hospitals). This does not 
include private duty nursing, or a television or 
telephone in your room. It also does not include a 
private room, unless medically necessary. Inpatient 
mental health care coverage in an independent 
psychiatric facility is limited to 190 days in a lifetime. 

Skilled Nursing Facility (SNF) Care: ** 
Semiprivate room, meals, skilled nursing and 
rehabilitative services, and other services and 
supplies (after a 3-day hospital stay). 
For more information on SNFs, see page 63. To get a 
booklet about SNF care, see page 66. 



For each benefit period YOU pay: 

• A total of $776 for a hospital stay of 1 -60 days. 

• $ 1 94 per day for days 6 1 -90 of a hospital stay. 

• $388 per day for days 91-150 of a hospital stay. 
(See Reserve Days on page 71.) 

• All costs for each day beyond 1 50 days. 



For each benefit period YOU pay: 

• Nothing for the first 20 days. 

• Up to $97 per day for days 21-100. 

• All costs beyond the 100th day in the benefit 
period. 

If you have questions about SNF care and conditions 
of coverage, call your Fiscal Intermediary (see pages 
29A-31). 



Home Health Care: ** Part-time skilled nursing 
care, physical therapy, occupational therapy, speech- 
language therapy, home health aide services, durable 
medical equipment (such as wheelchairs, hospital 
beds, oxygen, and walkers) and supplies, and other 
services (see page 49). To get a booklet about home 
health care, see page 66. 



YOU pay: 

• Nothing for home health care services. 

• 20% of the Medicare-approved amount for 

durable medical equipment. 

If you have questions about home health care and 
conditions of coverage, call your Regional Home 
Health Intermediary (see pages 32-33). 



Hospice Care: ** Medical and support services 
from a Medicare-approved hospice, drugs for 
symptom control and pain relief, short-term respite 
care, care in a hospice facility, hospital, or nursing 
home when necessary, and other services not 
otherwise covered by Medicare. Home care is also 
covered. To get a booklet about hospice care, see 
page 66. 



YOU pay: 

• A copayment of up to $5 for outpatient prescription 
drugs and 5% of the Medicare-approved payment 
amount for inpatient respite care (short-term care 
given to a hospice patient by another care giver, so 
that the usual care giver can rest). The amount you 
pay for respite care can change each year. 

If you have questions about hospice care and 
conditions of coverage, call your Regional Home 
Health Intermediary (see pages 32-33). 



Blood: Pints of blood you get at a hospital or skilled 
nursing facility during a covered stay. 



YOU pay: 

For the first 3 pints of blood, unless you or someone 
else donates blood to replace what you use. 



* New Part A and B amounts will be available by January 1, 2001. 

** You must meet certain conditions in order for Medicare to cover these services. 

If you have general questions about Medicare Part A, call your Fiscal Intermediary (see pages 29A-31). 
6 1-800-MEDICARE (1-800-633-4227) 



SECTION 2: YOUR MEDICARE BENEFITS 



What is Medicare 
PartB? 



: The new Part B 
premium amount 
will be available by 
January 1 , 200 1 . You 
may be able to get 
help from your state 
paying this premium 
(see page 1 1). 



Part B (Medical Insurance) 

Helps Pay For: Doctors' services, outpatient hospital care, 
and some other medical services that Part A does not cover, 
such as the services of physical and occupational therapists, 
and some home health care. Part B helps pay for these 
covered services and supplies when they are medically 
necessary (see pages 8-10). 

Cost: You pay the Medicare Part B premium of $45.50* per 
month. This is the 2000 amount and may change January 1, 
2001. In some cases, this amount may be higher if you did 
not choose Part B when you first became eligible at age 65. 
The cost of Part B may go up 10% for each 12-month 
period that you could have had Part B but did not sign 
up for it, except in special cases. You will have to pay this 
extra 10% for the rest of your life. For more Part B 
enrollment information, see page 53. 

Enrolling in Part B is your choice. You can sign up for Part 
B anytime during a 7-month period that begins 3 months 
before you turn 65. Visit your local Social Security office, or 
call the Social Security Administration at 1-800-772-1213 to 
sign up. If you choose to have Part B, the premium is usually 
taken out of your monthly Social Security, Railroad 
Retirement, or Civil Service Retirement payment. If you do 
not get any of these above payments, Medicare sends you a 
bill for your Part B premium every 3 months. You should get 
your Medicare premium bill by the 10th of the month. If you 
do not get your bill by the 10th, call the Social Security 
Administration at 1-800-772-1213 or your local Social 
Security office. If you get benefits from the Railroad 
Retirement Board, call your local RRB office or 
1-800-808-0772. 

For More Information: 

Call your Medicare Carrier about Part B bills and services 
(see pages 25A-F). 



www.medicare.gov 



SECTION 2: YOUR MEDICARE BENEFITS 



Medicare Part B (Medical Insurance) 
Helps Pay For: 



What YOU Pay in 2000* in the Original 
Medicare Plan (see Note below) 



Medical and Other Services: Doctors' services 
(except for routine physical exams), outpatient 
medical and surgical services and supplies, 
diagnostic tests, ambulatory surgery center facility 
fees for approved procedures, and durable medical 
equipment (such as wheelchairs, hospital beds, 
oxygen, and walkers). Also covers second surgical 
opinions. To get a booklet about second surgical 
opinions, see page 66. 

Also covers outpatient physical and occupational 
therapy including speech-language therapy. 

Outpatient mental health care. 



YOU pay: 

• $100 deductible (pay once per calendar year). 

• 20% of Medicare-approved amount after the 
deductible, except in the outpatient setting. (See Q12 
on page 56.) 



20% for all outpatient physical, occupational, and 
speech-language therapy services. 

50% for outpatient mental health care. (See Q25 on 
page 63.) 



Clinical Laboratory Service: 

urinalysis, and more. 



Blood tests, 



YOU pay: 

• Nothing for Medicare-approved services. 



Home Health Care: ** Part-time skilled care, 
home health aide services, durable medical 
equipment when supplied by a home health agency 
while getting Medicare-covered home health care, 
and other supplies and services. 



YOU pay: 

• Nothing for Medicare-approved services. 

• 20% of Medicare-approved amount for durable 
medical equipment. 



Outpatient Hospital Services: Services for the 
diagnosis or treatment of an illness or injury. 

To get a booklet about payment for outpatient 
hospital services, see page 67. 



YOU pay: 

• A coinsurance or fixed copayment amount which may 
vary according to the service. 



Blood: Pints of blood you get as an outpatient, or as 
part of a Part B covered service. 



YOU pay: 

For the first 3 pints of blood, then 20% of the 
Medicare-approved amount for additional pints of 
blood (after the deductible), unless you or someone 
else donates blood to replace what you use. 



* New Part A and B amounts will be available by January 1, 2001. 
f You must meet certain conditions in order for Medicare to cover these services or equipment. 

Note: Actual amounts you must pay are higher if the doctor or supplier does not accept assignment, and 
you may have to pay the entire cost. Medicare will then send you its share of the costs (see Q12 on 
page 56). If you have general questions about Medicare Part B, call your Medicare Carrier (see 
pages 25A-F). If you have questions about durable medical equipment, including diabetic supplies, 
call your DMERC (see page 28). 



1-800-MEDICARE (1-800-633-4227) 



SECTION 2: YOUR MEDICARE BENEFITS 



Medicare Part B Covered 
Preventive Services 



Who is 
covered... 



What YOU pay in the 
Original Medicare Plan. 



Bone Mass Measurements: 

Varies with your health status. 



Certain people with 
Medicare who are at 
risk for losing bone 
mass. 



20% of the Medicare-approved 
amount (or a set copayment 
amount) after the yearly Part B 
deductible. 



Colorectal Cancer Screening: 

• Fecal Occult Blood Test - Once every 12 months. 

• Flexible Sigmoidoscopy* - Once every 48 months. 

• Colonoscopy* - Once every 24 months if you 
are at high risk for cancer of the colon. 

• Barium Enema - Doctor can substitute for 
sigmoidoscopy or colonoscopy. 



All people with 
Medicare age 50 and 
older. However, there 
is no age limit for 
having a 
colonoscopy. 



Nothing for the fecal occult blood 
test. For all other tests, 20% of the 
Medicare-approved amount after 
the yearly Part B deductible. 
(*25% if performed in an 
ambulatory surgical center or 
hospital outpatient department.) 



Diabetes Services: 

• Coverage for glucose monitors, test strips, and 
lancets. 



• Diabetes self-management training. 



All people with 
Medicare who have 
diabetes (insulin 
users and non-users). 

If requested by your 
doctor or other 
provider. 



20% of the Medicare-approved 
amount after the yearly Part B 
deductible. 



20% of the Medicare-approved 
amount after the yearly Part B 
deductible. 



Mammogram Screening: 

Once every 12 months. (You can also get one 
baseline mammogram between ages 35 and 39.) 



All women with 
Medicare age 40 and 
older. 



20% of the Medicare-approved 
amount with no Part B 
deductible. 



Pap Smear and Pelvic Examination: All women with 
(Includes a clinical breast exam) Medicare. 
Once every 36 months. Once every 12 months if 
you are high risk for cervical or vaginal cancer, 
or if you are of childbearing age and have had an 
abnormal Pap smear in the preceding 36 months. 


Nothing for the Pap smear lab 
test. For Pap smear collection 
and pelvic and breast exams, 
20% of the Medicare-approved 
amount (or a set copayment 
amount) with no Part B 
deductible. 


Prostate Cancer Screening: All men with 

• Digital Rectal Examination - Once every 12 months. Medicare age 50 and 

• Prostate Specific Antigen (PSA) Test - older. 
Once every 12 months. 


Generally, 20% of the Medicare- 
approved amount for the digital 
rectal exam after the yearly Part B 
deductible. No coinsurance and no 
Part B deductible for the PSA Test. 


Shots (vaccinations): All people with 

• Flu Shot - Once a year in the fall or winter. Medicare. 

• Pneumonia Shot - One shot may be all you 
ever need. Ask your doctor. 

• Hepatitis B Shot - If you are at medium to high 
risk for hepatitis. 


Nothing for flu and pneumonia 
shots if the health care provider 
accepts assignment (see page 
56). For Hepatitis B shots, 20% 
of the Medicare-approved 
amount (or set copayment 
amount) after the yearly Part B 
deductible. 



www.medicare.gov 



SECTION 2: YOUR MEDICARE BENEFITS 



Part B also helps pay for: 

• Ambulance services (when other 
transportation would endanger your health). 

• Artificial limbs and eyes. 

• Braces - arm, leg, back, and neck. 

• Chiropractic services (limited). 

• Emergency care. 

• Eyeglasses - one pair after cataract surgery 
with an intraocular lens. 

• Immunosuppressive drug therapy (limited), 
extended coverage available for transplant 
patients including some ESRD patients. 

• Kidney dialysis and kidney transplants. 

• Medical supplies - items such as ostomy 



bags, surgical dressings, splints, casts, and 
some diabetic supplies. 

• Outpatient prescription drugs (very limited). 
For example, some oral cancer drugs. 

• Preventive services (see page 9). 

• Prosthetic devices, including breast 
prosthesis after mastectomy. 

• Services of practitioners such as clinical 
psychologists, social workers, and nurse 
practitioners. 

• Transplants - heart, lung, kidney, pancreas, 
and liver (under certain conditions). 

• X-rays and some other diagnostic tests. 



What is not paid for by Medicare Part A and Part B in the Original 
Medicare Plan? 

The Original Medicare Plan does not cover everything. Your out-of-pocket costs for health care 
will include but are not limited to: 



• Acupuncture. 

• Deductibles, coinsurance, or copayments 

when you get health care services (see the 
"What YOU Pay" part of the charts on pages 
6, 8, and 9). 

• Dental care and dentures (in most cases). 

• Cosmetic surgery. 

• Custodial care (help with bathing, dressing, 
toileting, and eating) at home or in a nursing 
home. 

• Health care you get while traveling outside 
of the United States (except in limited 
cases). 



Hearing aids. 

Orthopedic shoes. 

Outpatient prescription drugs (with only a 

few exceptions). 

Routine foot care. 

Routine eye care. 

Routine or yearly physical exams. 

Screening tests except those listed on page 9. 

Shots (vaccinations) except those listed on 

page 9. 

Your monthly Part B premium ($45.50 in 

2000*). 



■■ New Part A and B amounts will be available by January 1, 2001 



You may be able to get help with the costs Medicare does not cover (see page 1 1). You may be 
able to join a Medicare managed care plan or a Private Fee-for-Service plan and get extra 
benefits (see pages 16-22). 
10 1-800-MEDICARE (1-800-633-4227) 



SECTION 2: YOUR MEDICARE BENEFITS 

Getting help to pay your health care costs 

Most of your health care costs are covered if you have Medicare and you qualify 
for Medicaid. Medicaid is a joint federal and state program that helps pay medical 
costs for some people with low incomes and limited resources. Medicaid programs 
vary from state to state. People on Medicaid may also get coverage for nursing 
home care and outpatient prescription drugs which are not covered by Medicare. 



States also have programs that pay some or all of Medicare's premiums and may 
also pay Medicare deductibles and coinsurance for certain people who have 
Medicare and a low income. 
To qualify, you must have: 

• Part A (Hospital Insurance, see page 5 for more information about Part A), 

• Assets, such as bank accounts, stocks, and bonds that are not more than $4,000 
for a single person, or $6,000 for a couple, and 

• A monthly income that is below certain limits (see chart below). 

Programs That Help Pay Medical Expenses* 

Monthly Income Limits for Program Will Pay Program Name 

2000** 



$716 Individual or $958 Couple 



Premiums, deductibles, and 
coinsurance 



Qualified Medicare Beneficiary 
(QMB) 



$855 Individual or $1,145 Couple Medicare Part B premiums 



Specified Low-Income Medicare 
Beneficiary (SLMB) 



$960 Individual or $ 1 ,286 Couple Medicare Part B premiums 



Qualifying Individual (QI-1) 



$1,238 Individual or $1,661 Couple 



A small part of your Medicare 
Part B premiums 



Qualifying Individual (QI-2) 



*These programs may not be available in Guam, Puerto Rico, the Virgin Islands, 
the Northern Mariana Islands, and American Samoa. 

**Slightly higher income amounts are allowed in Alaska and Hawaii. Income limits 
will go up slightly in 2001, and new limits will be available by April 1, 2001. 

For more information about these programs, call your state medical assistance office (see 
pages 42-43). If you need more help, please call 1-800-MEDICARE (1-800-633-4227). 
The customer service representative will help you find the phone number in your State. 

For information about supplement insurance (Medigap), see page 15. 



Insure Kids Now 

Free or low-cost health insurance is available now in your State for uninsured children under 
age 19. Call toll-free 1-877-KIDS-NOW (1-877-543-7669) for more details. 



www.medicare.gov 



11 



SECTION 3: MEDICARE HEALTH PLANS 

Other Kinds of Health Insurance You Might Have 

Do you know what health care insurance you have and what it helps pay for? Fall is a good 
time to review your coverage. Medicare may not be the only health care coverage you can get. 
You might be able to get more health care coverage, help to lower your out-of-pocket costs, or 
more benefits than Medicare alone has. Check with your current or past employer or union, or 
the military if you are a veteran or military retiree. You might be able to get insurance through 
them. This kind of insurance can help pay the costs Medicare does not pay. 

Whether you qualify for employer, union, military, or other health care coverage, you should 
learn about all of the different kinds of health care coverage. What you choose will affect how 
much you pay, what benefits you may have, which doctors you can see, and other things that 
may be important to you. 

If you or your spouse still work or are retired, you may be able to get employer 
or union health care coverage: 

• Call the employer or union to find out if you can get health care coverage based on your or 
your spouse's past or present employment. 

• If you can get this coverage, ask your benefits administrator to help you compare their costs 
and benefits to Medicare's. In addition, there are rules about who pays first (see page 67 to 
get a booklet about who pays first). 

Caution: If you already have employer or union coverage, talk to your employer or union 

before you make any changes. If you drop this coverage, you may not be able to get 
it back. 



If you are a veteran or a military retiree, you may be able to get health care 
benefits: 

• If you are a veteran, call the US. Department of Veteran Affairs at 1-800-827-1000. If 
you or your spouse are retired from the military, call the Department of Defense at 
1-800-538-9552 for more information. 



If you have a low income and limited assets, you may qualify for help paying 
your health care costs: 

• See page 1 1 to see if you qualify for help from your state to pay your health care costs. You 
may also call your state medical assistance office (see pages 42-43). 

Note: For information about Medicare Supplement Insurance (Medigap), see page 15. 
12 1-800-MEDICARE (1-800-633-4227) 



SECTION 3: MEDICARE HEALTH PLANS 



Medicare health 
plan choices in 
2001 



In Medicare, you may be able to get your health care 
coverage from: 

• The Original Medicare Plan (see pages 14-15). 

Or, you can get your coverage through another Medicare 
health plan under Medicare + Choice. Congress created the 
Medicare + Choice program to let more private insurance 
companies offer coverage to people in Medicare. Some of 
your choices may include: 

• A Medicare managed care plan, like an HMO (see 
pages 16-22), or 

•A Medicare Private Fee-for-Service plan (see pages 17-22). 

These are the only types of Medicare health plans currently 
available. 

No matter how you get your Medicare benefits, you 
are still in the Medicare program. 

In every Medicare health plan: 

• You pay the monthly Medicare Part B premium of $45.50 
in 2000. It is usually taken out of your monthly Social 
Security, Railroad Retirement, or Civil Service Retirement 
payment. 

• You get all the Medicare Part A and Part B covered services. 



When 
choosing a 
Medicare 
health 
plan, think 
about: 



Cost 



Doctor Choice 
Benefits 



Convenience 
Quality 



What will my out-of-pocket costs be? 

Can I see the doctor(s) I want to see? 

Do I need extra benefits and services, like prescription 
drugs, eye exams, hearing aids, or routine physical exams? 

Where are the doctors' offices and what are their hours? 

How well does the plan keep its members healthy or treat 
them when they are sick? Call 1-800-MEDICARE 
(1-800-633-4227) or look at www.medicare.gov on the 
Internet for information on Medicare health plan quality. 
Quality information is not available yet for Medicare 
Private Fee-for-Service plans because they are new. 
www.medicare.gov 1 3 



SECTION 3: MEDICARE HEALTH PLANS 



The Original 
Medicare Plan 



How does the Original 
Medicare Plan work? 



The Original Medicare Plan is also known as "fee-for- 
service." This plan, offered by the federal government, is 
available nationwide. You are usually charged a fee for each 
health care service or supply you get. If you are happy 
getting your health care this way, you do not have to change. 
You will stay in the Original Medicare Plan unless you 
choose to join a Medicare managed care plan or a Private 
Fee-for-Service plan. 

If you are in the Original Medicare Plan, you use your red, 
white, and blue Medicare card when you get health care (see 
the sample card on page 5). 

• You may go to any doctor, specialist, or hospital that 
accepts Medicare. Generally, a fee is charged each time you 
get a service. 

• You pay the monthly Part B premium of $45.50 in 2000. 

• You pay an amount for your health care each year 
(deductible) before Medicare pays its part. Then, Medicare 
pays its share, and you pay your share (coinsurance). After 
you get a health care service, you get an Explanation of 
Medicare Benefits or a Medicare Summary Notice in the 
mail. These are sent by a company that handles bills for 
Medicare. The notice lists the amount you may be billed. 



Your costs in the 
Original Medicare 
Plan 



What you pay out-of-pocket depends on: 

• Whether your doctor or supplier agrees to accept 
assignment (see Q12 on page 56). 

• How often you need health care. 

• What type of health care you need. 

• Whether you get health care while traveling outside of the 
United States, since in most cases, you would pay for this 
care. 

• Whether you get services or supplies not covered by 
Medicare. 



14 



1-800-MEDICARE (1-800-633-4227) 



SECTION 3: MEDICARE HEALTH PLANS 



Your costs in the 
Original Medicare 
Plan (continued) 



* For the rest of this 
book, Medicare 
Supplement 
Insurance policies 
will be called 
Medigap policies. 



Filling the gaps in Original 
Medicare Plan coverage 

What is a Medigap 
policy? 



To help cover the costs the Original Medicare Plan does not 
cover, you can: 

• Keep or get employer or union health coverage (see page 
12), or 

• Buy a Medigap Policy (Medicare Supplement Insurance)* 
(see below), or 

• Check if you qualify for help from your State (see page 

id. 

You may be able to save money by joining one of the other 
Medicare health plans (see pages 16-22). 

For more information on the Original Medicare Plan, see 
Ql 1 and Q12 on page 56. 



A "Medigap" policy fills gaps in Original Medicare Plan 
coverage. Medigap insurance must follow federal and state 
laws. These laws protect you. All Medigap policies are 
clearly marked "Medicare Supplement Insurance." 

In all states, except Massachusetts, Minnesota, and 
Wisconsin, a Medigap policy must be one often 
standardized policies to help you compare them easily. Each 
policy has a different set of benefits. Two of the standardized 
policies may have a high deductible option. In addition, any 
standardized policy may be sold as a "Medicare SELECT" 
policy. Medicare SELECT policies usually cost less because 
you must use certain hospitals and doctors. In an emergency, 
you may use any doctor or hospital. 

For more information about Medigap policies: 

• Read Q13-Q16 on pages 57-60. 

• Call 1-800-MEDIC ARE (1-800-633-4227) and ask for a 
free copy of the 2000 Guide to Health Insurance for People 
with Medicare. You can also look on the Internet at 
www.medicare.gov to read or print this booklet. 

www.niedicarc.gov 15 



SECTION 3: MEDICARE HEALTH PLANS 



Medicare managed 
care plans and 
Private Fee-for- 
Service Plans 



Medicare managed care plans and Private Fee-for-Service 
plans are not available in all areas. If you are in either of 
these types of plans, you must continue to pay the monthly 
Medicare Part B premium of $45.50 in 2000. You may also 
have to pay any additional monthly premium. 



What is a Medicare 
managed care plan? 



A Medicare managed care plan, sometimes called an HMO, 
is a health plan offered by private insurance companies. 
Many people with Medicare choose a managed care plan. 



How does managed 
care work? 



Medicare pays a set amount of money every month to the 
private insurance company. 

You can often get extra benefits, like prescription drugs. 

In most managed care plans, you can only go to certain 
doctors and hospitals that agree to treat members of the plan. 
Call the plan you are interested in to see which doctors are 
in the plan. 

Doctors can join or leave managed care plans at any time. 
If your doctor leaves your plan, ask your plan for the names 
of plan doctors in your area. If you want to keep getting 
care from your doctor, ask if he or she belongs to another 
Medicare managed care plan. You may want to join that 
plan. 

Generally, you can only see a specialist (like a cardiologist) 
when you get a referral, which means your primary care 
doctor says it is OK to go. 

Some managed care plans offer a Point-of-Service option. 
This allows you to go to other doctors and hospitals who 
are not a part of the plan. Most of the time this option costs 
you more, and gives you more choices. 



16 



1-800-MEDICARE (1-800-633-4227) 



SECTION 3: MEDICARE HEALTH PLANS 



What is a Private 

Fee-for-Service 

plan? 



How does a Private 
Fee-for-Service plan 
work? 



Caution: Ask the plan if it 
has any "pre-notification" 
requirements (for example, a 
requirement that you notify 
the plan of any planned 
inpatient admissions). 



This is a new type of health care plan in some areas of the 
country. A Private Fee-for-Service plan is a Medicare health 
plan offered by a private insurance company. It is not the 
same as the Original Medicare Plan, which is offered by the 
federal government. 

• Medicare pays a set amount of money every month to the 
private insurance company. 

• The private insurance company provides health care 
coverage to people with Medicare who join this plan. You 
pay and the insurance company pays a fee for each doctor 
visit or service you get. 

• The insurance company, rather than the Medicare program, 
decides how much it pays, and how much you pay, for the 
services you get. 

• You can go to any doctor or hospital that accepts the plan's 
payment. 

• You may be able to get extra benefits, like coverage for 
additional days in the hospital. 



Who can join a 
Medicare managed 
care plan or Private 
Fee-for-Service 
plan? 



Note: If you are 
already in a Medicare 
managed care plan and 
have only Part B, you 
may stay in your plan. 



If you have Medicare, you can join either of these types of 
plans if: 

• You have both Part A (Hospital Insurance) and Part B 
(Medical Insurance). 

• You live in the service area of the plan. The service area is 
where the plan accepts members. In the case of a managed 
care plan, it's also where you get services from the plan. 

• You do not have End-Stage Renal Disease (permanent 
kidney failure requiring dialysis or a kidney transplant). 
ESRD patients can stay in the plan they are in or join 
another plan offered by the same company. If you've had a 
successful kidney transplant, you may be able to join a 
plan. Call 1-800-MEDIC ARE (1-800-633-4227) for more 
information about End-Stage Renal Disease and Medicare 
health plans. 

www.medicare.gov 17 



SECTION 3: MEDICARE HEALTH PLANS 



If you join one of 
these plans: 



• You are still in the Medicare program. 

• You must continue to pay the monthly Medicare Part B 
premium of $45.50 in 2000. 

• You still get all your regular Medicare-covered services 
(see pages 6, 8, and 9). 

• You have Medicare rights and protections 
(see pages 45-51). 



Your costs in a 
Medicare managed 
care plan or 
Private Fee-for- 
Service plan 



What you pay out-of-pocket depends on: 

• Whether the plan charges a monthly premium in addition 
to your monthly Part B premium of $45.50 in 2000. 

Note: If you don't pay the additional premium charged by 
your plan, you may be returned to the Original Medicare 
Plan. 

• How much the plan decides you must pay for each visit. 

• The type of health care you need and how often you get it. 

• How much the plan charges for extra benefits. 

Also: 

• In a Medicare managed care plan, you may pay more if 
you get health care outside the service area of the plan. See 
exceptions for emergency and urgently needed care on 
page 62 (Q23 and Q24). 

• In a Private Fee-for-Service plan, you may pay more if the 
plan lets doctors, hospitals, and other providers bill you 
more than the plan pays for services. If this is allowed, 
there may be a limit to what they can charge, and you must 
pay the difference. 



18 



1-800-MEDIC A RE (1-800-633-4227) 



SECTION 3: MEDICARE HEALTH PLANS 



How can I tell if I 
am in a Medicare 
managed care plan 
or Private Fee-for- 
Service plan? 



If you joined a Medicare managed care plan or Private Fee- 
for-Service plan, you should have a membership card with 
the name of the plan on it. If you are not sure if you are in 
one of these plans, you can call the number listed on your 
membership card, or call the Social Security Administration 
at 1-800-772-1213, or call your local Social Security Office 
to find out. If you get benefits from the Railroad Retirement 
Board, call your local RRB office or 1-800-808-0772. 



When can I join 
one of these plans? 



During the month of November, Medicare health plans must 
accept new members. In most cases, if you join a Medicare 
health plan in November 2000, your coverage begins on 
January 1, 2001. 

Most Medicare health plans may also accept new members 
at other times of the year. Some Medicare health plans limit 
the number of members in their plans. These plans may not 
accept new members all of the time. A plan can tell you if it 
is signing up new members. 



How do I join a 
Medicare managed 
care plan or Private 
Fee-for-Service 
plan? 



To join a plan: 

1 . Call the plan and ask for an enrollment form. Fill out the 
form and mail it to the plan, or 

2. Get an enrollment form from a plan representative. Fill 
out the form and give it to the plan representative. 

You will get a letter from the plan telling you when your 
coverage begins. 



Can I join more 
than one plan? 



No. You can't join more than one Medicare health plan at the 
same time. If you try to join more than one Medicare health 
plan with the same starting dates, you may end up enrolled 
in the plan you did not want to be in. 



www.medicare.gov 



19 



SECTION 3: MEDICARE HEALTH PLANS 



What if I move out 
of the plan's service 
area? 



You will need to call the health plan to see if you can stay in 
the plan if you move out of the plan's service area. If you 
must leave the plan, you must disenroll. You will be covered 
under the Original Medicare Plan. Or, you can choose to join 
another Medicare health plan, if one is available in your 
area. 



What if I want to 
leave the plan? 



In the year 2001, you may leave a plan at any time for any 
reason. Write to the plan or to the Social Security 
Administration. Tell them you want to leave the plan. The 
plan should send you a letter with the date your plan 
coverage ends. If you don't get a letter, call the plan and ask 
for the date. When you leave a plan, you are automatically 
returned to the Original Medicare Plan, unless you join 
another Medicare managed care plan or Private Fee-for- 
Service plan. If you join another one of these plans, you 
should get a letter telling you when your coverage starts. 

Starting in 2002, you may be able to leave a plan only at 
certain times. Call 1-800-MEDIC ARE (1-800-633-4227) for 
more information. 

If you join a new Medicare managed care plan or Private 
Fee-for-Service plan and change your mind, you must write 
to the new plan. Tell them you want to cancel. 

If you change your mind and your new plan has: 

• not processed your enrollment, you can stay in your old 
plan (including the Original Medicare Plan), or you can 
join a new Medicare health plan. 

• already processed your enrollment, you will be disenrolled 
from your old plan and enrolled in the new plan. If you 
want to return to your old plan, you have to re-enroll in it. 
If your old plan was the Original Medicare Plan, you will 
be returned to it when you disenroll from the new plan. 



20 



1-800-MEDICARE (1-800-633-4227) 



SECTION 3: MEDICARE HEALTH PLANS 



Can I keep my 
Medigap policy if I 
join one of these 
plans? 



Yes, you can keep it. However, it may cost you a lot and you 
may get little benefit from it while you are in a Medicare 
managed care plan or Private Fee-for-Service plan. If you 
drop your Medigap policy, you may not be able to get it 
back unless you are in a situation listed in Q15 on 
pages 58-59. 



Who decides where 
Medicare managed 
care plans and 
Private Fee-for- 
Service plans will 
be available? 



Medicare managed care plans and Private Fee-for-Service 
plans are offered by private companies. 

A company can decide that a plan will be available to 
everyone with Medicare in a state, or be open only in certain 
counties. The company may also choose to offer more than 
one plan in an area, with different benefits and costs. Each 
year, the companies offering Medicare managed care plans 
and Private Fee-for-Service plans can decide to join or leave 
Medicare. 



How long are 
Medicare managed 
care plans and 
Private Fee-for- 
Service plans 
required to stay in 
Medicare? When 
can they leave 
Medicare? 



When Medicare health plans sign a contract with Medicare, 
they agree to stay in Medicare for at least one year 
(January 1 through December 31). Private companies offer 
managed care plans and Private Fee-for-Service plans. Each 
year, they make a business decision to stay in or leave the 
Medicare program. Costs and extra benefits can also change. 

Your plan must let you know if they intend to leave 
Medicare at the end of the year. You will be notified before 
your plan coverage ends. The notice the plan must send you 
will tell you if other Medicare health plans are offered in 
your area, and what protections you have. 

If the plan's quality is poor or they commit fraud, a plan can 
be asked to leave the Medicare program at any time during 
the year. You will get a notice before this happens. The 
notice will tell you how to find a new plan, and what 
protections you have. 



www.medicarc.gov 



21 



SECTION 3: MEDICARE HEALTH PLANS 



What if I have 
employer or union 
coverage? 



If you join a Medicare managed care plan or Private Fee-for- 
Service plan and also have employer or union coverage, you 
may, in some cases, still be able to use this coverage along 
with your Medicare health plan coverage. Talk to your 
benefits administrator about the rules that apply. 



Medicare Medical 
Savings Account 
Plans 



You may have heard about Medicare Medical Savings 

Accounts. At the time this handbook was printed, no 
private insurance companies were offering these types of 
plans to people with Medicare. To find out if any of these 
plans have become available in your area, or to learn more 
about them, call 1-800-MEDICARE (1-800-633-4227) and 
ask for a free copy of Your Guide to Medicare Medical 
Savings Accounts. 



For more 
information about 
your Medicare 
health plan choices: 



Moving? 
Call 1-800-MEDICARE 
(1-800-633-4227), or look 
on the Internet at 
www.medicare.gov. Click 
on Medicare Health Plan 
Compare to get more 
information on plans in 
your new area. 
Remember to call the 
Social Security 
Administration at 
1-800-772-1213 to change 
your address. 



1. See Q17-Q24 on pages 60-62. 

2. Call 1-800-MEDICARE (1-800-633-4227, TTY/TDD: 
1-877-486-2048 for the hearing and speech impaired) and 
ask for: 

• A free copy of detailed plan information on costs, extra 
benefits, quality, and disenrollment information for 
plans in your area. 

• A free copy of The Worksheet for Comparing Medicare 
Health Plans to help you compare plans. 

• A free copy of Your Guide to Private Fee-for-Service 
Plans. 

3. Look on the Internet at www.medicare.gov to find plan 
information for your area, including their costs, extra 
benefits, quality, and disenrollment information, and 
booklets that you can read or print out. 



22 



1-800-MEDICARE (1-800-633-4227) 



SECTION 4: WHERE TO CALL FOR HELP 

Where to call for help with your Medicare questions 

The next 29 pages have phone numbers you may call for help. If there is a special number for 
your state, it will be listed. 

! If you have questions about... Call... 

Changing your address, Medicare Part A or Part B, lost Social Security Administration (SSA) 

Medicare card, and Social Security benefits (see page 24). 

Medigap policies, long-term care insurance, Medicare health State Health Insurance Assistance 
iplan choices, Medicare rights and protections, and help with Program 
filing an appeal (see pages 26-27). 

iPart B bills, services, and fraud and abuse (see pages 25 A-F). Medicare Carrier 

IPart A bills and services, hospital care, skilled nursing care, Fiscal Intermediary (FI) 
and fraud and abuse (see pages 29A-3 1 ). 

General Medicare information, ordering Medicare booklets, and 1-800-MEDICARE Helpline 
information about health plans (see page 24). 

Discrimination (see page 44). Office for Civil Rights 

(Reporting fraud and abuse (see page 24). Office of the Inspector General 

Complaints about quality of care, and filing an appeal or Peer Review Organization (PRO) 

complaint (see pages 34-39). 

Medigap policies available in your area, and insurance State Insurance Department 

questions (see pages 40-41). 

Low-income programs to help pay medical bills (see pages 42-43 ). State Medical Assistance Office 

Medicare bills and coverage, RRB benefits, lost Medicare Railroad Retirement Board (RRB) 

card, Medicare premium amounts, and enrolling in Medicare ( Railroad Retirement beneficiaries 
(see page 24). onl y) 

If you are enrolled in a Medicare managed care plan or Private Fee-for-Service plan, you should 
call your plan with questions about bills, health services, and appeals. 

Note: At the time of printing, telephone numbers listed were correct. Phone numbers sometimes 
change. To get the most up-to-date phone numbers, call 1-800-MEDICARE (1-800-633-4227, 
TTY/TDD: 1-877-486-2048 for the hearing and speech impaired) or go to the Internet at 
www.medicare.gov and click on Helpful Contacts. 

www.medicare.gov 23 



SECTION 4: WHERE TO CALL FOR HELP 



The telephone numbers on this page are the same for all states. 



All States 



1-800-MEDICARE Helpline 

Call about: 

• Information about health plans 

• Ordering Medicare booklets 

• General Medicare information 

• TTY/TDD and local phone numbers 

• Information about health information fairs in your area 



1-800-MEDICARE 
1-800-633-4227 
TTY/TDD: 1-877-486-2048 



Coordination of Benefits Contractor 

Call about: 

• Medicare Secondary Payer 

• Questions about who pays first 



All States 



1-800-999-1118 



Department of Health and Human Services 
Office of the Inspector General 

Call about: 

• Reporting fraud and abuse in any federal 
health care program 



All States 1-800-447-8477 

TTY/TDD: 1-800-377-4950 



Railroad Retirement Board 

Call about: 

• Signing up for Medicare Part A and Part B, 
lost RRB Medicare card, address change 

• Part B bills and services (Palmetto GBA 
1-800-833-4455) 

Part A bills and services (see Fiscal 
Intermediary on pages 29A-3 1 ) 



All States 



(RRB Beneficiaries Only) 



■800-808-0772 



Social Security Administration 

ICall about: 

Changing your address 

Lost Medicare card 

Signing up for Medicare Part A and Part B 

Medicare premium problems 



All States 



1-800-772-1213 
TTY/TDD: 1-800-325-0778 



Veterans Administration 

ICall about: 
Medical benefits 



All States 



-800-827-1000 



24 



1-800-MEDICARE (1-800-633-4227) 



SECTION 4: WHERE TO CALL FOR HELP 



Medicare Carrier: Call about questions on Medicare Part B coverage, bills and medical 
services, or for information on how to recognize Medicare fraud and abuse. If you get benefits 
from the Railroad Retirement Board, see page 24. 



Alabama 


Arizona 


Colorado 


Blue Cross Blue Shield of 


Noridian Mutual Insurance 


Noridian Mutual Insurance 


Alabama, 


Company, 


Company, 


1(800)292-8855 


1(800)444-4606 


1(800)332-6681 


TTY/TDD: 1(800)548-2547 


TTY/TDD: 1(303)858-5903 


TTY/TDD: 1(303)858-5903 


Alaska 


Arkansas 


Connecticut 


Noridian Mutual Insurance 


Blue Cross Blue Shield of 


Florida Blue Cross Blue 


Company, 


Arkansas, 


Shield, 


1(800)444-4606 


1(800)482-5525 in-state 


1(800)982-6819 in-state 


TTY/TDD: 1(303)858-5903 


calls only 


calls only 




TTY/TDD: 1(501)378-3009 


TTY/TDD: 1(203)639-3059 


American Samoa 


California 


Delaware 


Noridian Mutual Insurance 


National Heritage Insurance 


Trailblazer Health 


Company, 


Company, 


Enterprises, 


1(800)444-4606 


1(800)952-8627 in-state 


1(800)444-4606 


TTY/TDD: 1(303)858-5903 


calls only 

TTY/TDD: 1(530)634-7538 

www.medicare.2ov 


TTY/TDD: 1(877)486-2048 

25 -A 



SECTION 4: WHERE TO CALL FOR HELP 

Medicare Carrier: Call about questions on Medicare Part B coverage, bills and medical 
services, or for information on how to recognize Medicare fraud and abuse. 





Florida 

Blue Cross Blue Shield, 
1(800)333-7586 in-state calls only 
TTY/TDD: 1(800)754-7820 


Indiana 

Adminastar Federal, 
1(800)622-4792 
TTY/TDD: 1(877)486-2048 




Georgia 

Cahaba Government Benefit 
Administration, 
1(800)727-0827 
TTY/TDD: 1(800)377-4950 


Iowa 

Noridian Mutual Insurance Company, 

1(800)532-1285 

TTY/TDD: 1(800)735-2943 




Guam 

Noridian Mutual Insurance Company, 

1(800)444-4606 

TTY/TDD: 1(303)858-5903 


Kansas 

Blue Cross Blue Shield of Kansas, 
1(800)432-3531 in-state calls only 
TTY/TDD: 1(800)430-8757 




Hawaii 

Noridian Mutual Insurance Company, 

1(800)444-4606 

TTY/TDD: 1(303)858-5903 


Kentucky 

Adminastar Federal, 
1(800)999-7608 
TTY/TDD: 1(317)841-4677 


Idaho 

Cigna Medicare, 

1(800)627-2782 in-state calls only 
TTY/TDD: 1(800)627-2782 


Louisiana 

Louisiana Medicare - Part B, 
1(800)462-9666 in-state calls only 
TTY/TDD: 1(225)231-2292 


Illinois 

Wisconsin Physicians Service, 
1(800)642-6930 
TTY/TDD: 1(800)535-6152 


Maine 

National Heritage Insurance Company, 

1(800)882-1228 

TTY/TDD: 1(800)559-0443 



25 -B 



1-800-MEDICARE (1-800-633-4227) 



SECTION 4: WHERE TO CALL FOR HELP 



Medicare Carrier: Call about questions on Medicare Part B coverage, bills and medical 
services, or for information on how to recognize Medicare fraud and abuse. 



Maryland 

Trailblazer Health 
Enterprises, 
1(800)444-4606 
TTY/TDD: 1(877)486-2048 



Minnesota 

Wisconsin Physician 

Services, 

1(800)352-2762 in-state 

calls only 

TTY/TDD: 1(800)627-3529 



Montana 

Blue Cross Blue Shield of 

Montana, 

1(800)332-6146 in-state 

calls only 

TTY/TDD: 1(800)238-5086 



Massachusetts 

National Heritage Insurance 
Company, 
1(800)882-1228 
TTY/TDD: 1(800)559-0443 



Mississippi 

Cahaba Health Benefits 

Administration, 

1(800)682-5417 in-state 

calls only 

TTY/TDD: 1(601)977-5820 



Nebraska 

Blue Cross Blue Shield, 
1(800)633-1113 
TTY/TDD: 1(800)430-8757 



Michigan 

Wisconsin Physicians 
Service, 
1(800)482-4045 
TTY/TDD: 1(800)535-6152 



Missouri 

Blue Cross Blue Shield of 

Arkansas, 

1(800)392-3070 in-state 

calls only 

TTY/TDD: 1(877)645-9577 

Eastern Missouri 

Blue Cross Blue Shield, 

1(800)892-5900 

TTY/TDD: 1(800)430-8757 
Kansas City Area 



Nevada 

Noridian Mutual Insurance 
Company, 
1(800)444-4606 
TTY/TDD: 1(303)858-5903 



www.medicare.gov 



25 -C 



SECTION 4: WHERE TO CALL FOR HELP 

Medicare Carrier: Call about questions on Medicare Part B coverage, bills and medical 
services, or for information on how to recognize Medicare fraud and abuse. 



New Hampshire 

National Heritage Insurance 
Company, 
1(800)882-1228 
TTY/TDD: 1(800)559-0443 



New York 

Blue Cross Blue Shield, 
1(800)252-6550 
TTY/TDD: 1(877)486-2048 
Services Upstate NY 

Empire Medicare Services, 
1(800)442-8430 
TTY/TDD: 1(516)244-5101 

Group Health, Inc., 

1(800)632-5572 

TTY/TDD: 1(212)721-1782 
Queens County only 



Northern Mariana 
Islands 

Noridian Mutual Insurance 
Company, 
1(800)444-4606 
TTY/TDD: 1(303)858-5903 



New Jersey 

Empire Medicare Services - 
New Jersey Operations, 
1(800)462-9306 
TTY/TDD: 1(800)992-0165 



North Carolina 

Cigna Medicare, 
1(800)672-3071 in-state 
calls only 
TTY/TDD: 1(800)686-5517 



Ohio 

Nationwide Mutual 
Insurance Company, 
1(800)282-0530 
TTY/TDD: 1(800)542-5250 



New Mexico 

Blue Cross Blue Shield of 
Arkansas, 
1(800)423-2925 
TTY/TDD: 1(800)822-9472 



North Dakota 

Noridian Mutual Insurance 
Company, 
1(800)247-2267 
TTY/TDD: 1(303)858-5903 



Oklahoma 

Blue Cross Blue Shield of 
Arkansas, 
1(800)522-9079 
TTY/TDD: 1(800)822-9472 



25 -D 



1-800-MEDICARE (1-800-633-4227) 



SECTION 4: WHERE TO CALL FOR HELP 

Medicare Carrier: Call about questions on Medicare Part B coverage, bills and medical 
services, or for information on how to recognize Medicare fraud and abuse. 



Oregon 

Noridian Mutual Insurance Company, 

1(800)444-4606 

TTY/TDD: 1(303)858-5903 


Tennessee 

Cigna Medicare, 

1(800)342-8900 in-state calls only 
TTY/TDD: 1(800)686-5485 




Pennsylvania 

HGS Administrators, 
1(800)746-5680 
TTY/TDD: 1(800)242-8471 


Texas 

Trailblazer Health Enterprises, 
1(800)442-2620 
TTY/TDD: 1(800)516-6684 




Puerto Rico 

Triple S, Inc., 

1(800)981-7015 in-state calls only 

TTY/TDD: 1(787)782-5430 


Utah 

Blue Cross Blue Shield, 
1(800)426-3477 
TTY/TDD: 1(800)346-4128 




Rhode Island 

Blue Cross Blue Shield of Rhode Island, 

1(800)662-5170 

TTY/TDD: 1(888)239-3356 


Vermont 

National Heritage Insurance Company, 

1(800)882-1228 

TTY/TDD: 1(800)559-0443 


Erl 


South Carolina 

Palmetto Government Benefits 
Administrator, 
1(800)868-2522 
TTY/TDD: 1(800)223-1296 


Virgin Islands 

Triple S, Inc., 

1(800)474-7448 in-state calls only 


m 


South Dakota 

Noridian Mutual Insurance Company, 

1(800)437-4762 

TTY/TDD: 1(303)858-5903 





www.medicare.gov 



25 -E 



SECTION 4: WHERE TO CALL FOR HELP 



Medicare Carrier: Call about questions on Medicare Part B coverage, bills and medical 
services, or for information on how to recognize Medicare fraud and abuse. 





Virginia 

Trailblazer Health 

Enterprises, 

1(800)444-4606 


West Virginia 

Nationwide Mutual 
Insurance Company, 
1(800)848-0106 
TTY/TDD: 1(800)542-5250 


}•>■ 


Washington 

Noridian Mutual Insurance 
Company, 
1(800)444-4606 
TTY/TDD: 1(303)858-5903 


Wisconsin 

Wisconsin Physicians 

Service, 

1(800)944-0051 in-state 

calls only 

TTY/TDD: 1(800)828-2837 




Washington, D.C. 

Trailblazer Health 
Enterprises, 
1(800)444-4606 
TTY/TDD: 1(877)486-2048 


Wyoming 

Noridian Mutual Insurance 
Company, 
1(800)442-2371 
TTY/TDD: 1(303)858-5903 



25 -F 



1-800-MEDICARE (1-800-633-4227) 



SECTION 4: WHERE TO CALL FOR HELP 



State Health Insurance Assistance Program: Call for help with buying a Medigap 
policy or long-term care insurance, dealing with payment denials or appeals, Medicare rights 
and protections, help with complaints about your care or treatment, help choosing a Medicare 
health plan, or Medicare bills. 



Alabama 

1(800)243-5463 in 


-state calls 


only 


Illinois 

1(800)548-9034 in-state calls only 




Alaska 

1(800)478-6065 in 


-state calls 


only 


Indiana 

1(800)452-4800 




American Samoa 

1(808)586-7299 


Iowa 

1(800)351-4664 




Arizona 

1(800)432-4040 


Kansas 

1(800)860-5260 in-state calls only 




Arkansas 

1(800)224-6330 


Kentucky 

1(877)293-7447 in-state calls only 




California 

1(800)434-0222 


Louisiana 

1(800)259-5301 in-state calls only 




Colorado 

1(888)696-7213 


Maine 

1(800)750-5353 in-state calls only 




Connecticut 

1(800)994-9422 in 


-state calls 


only 


Maryland 

1(800)243-3425 in-state calls only 




Delaware 

1(800)336-9500 in 


-state 


calls only 


Massachusetts 

1(800)882-2003 in-state calls only 


Erl 


Florida 

1(800)963-5337 in 


-state 


calls only 


Michigan 

1(800)803-7174 


'-6 


Georgia 

1(800)669-8387 


Minnesota 

1(800)333-2433 




Guam 

1(808)586-7299 


Mississippi 

1(800)948-3090 




Hawaii 

1(808)586-7299 


Missouri 

1(800)390-3330 




Idaho 

1(800)247-4422 in- 


-state 


calls only 

www.met 


Montana 

1(800)332-2272 in-state calls only 

licare.gov 26 





SECTION 4: WHERE TO CALL FOR HELP 



State Health Insurance Assistance Program: Call for help with buying a Medigap 
policy or long-term care insurance, dealing with payment denials or appeals, Medicare rights 
and protections, help with complaints about your care or treatment, help choosing a Medicare 
health plan, or Medicare bills. 





Nebraska 

1(800)234-7119 


Rhode Island 

1(800)322-2880 in-state calls only 


Nevada 

1(800)307-4444 


South Carolina 

1(800)868-9095 in-state calls only 


New Hampshire 

1(800)852-3388 in-state calls only 


South Dakota 

1(605)773-3656 


New Jersey 

1(800)792-8820 in-state calls only 


Tennessee 

1(800)525-2816 


New Mexico 

1(800)432-2080 in-state calls only 


Texas 

1(800)252-9240 


New York 

1(800)333-4114 


Utah 

1(800)541-7735 in-state calls only 




North Carolina 

1(800)443-9354 in-state calls only 


Vermont 

1(800)642-51 19 in-state calls only 


North Dakota 

1(800)247-0560 in-state calls only 


Virgin Islands 

1(340)778-6311 x2338 




Northern Mariana Islands 

1(808)586-7299 


Virginia 

1(800)552-3402 


Ohio 

1(800)686-1578 in-state calls only 


Washington 

1(800)397-4422 


Oklahoma 

1(800)763-2828 in-state calls only 


Washington, D.C. 

1(202)739-0668 


Oregon 

1(800)722-4134 in-state calls only 


West Virginia 

1(877)987-4463 


Pennsylvania 

1(800)783-7067 


Wisconsin 

1(877)333-0202 


Puerto Rico 

1(877)725-4300 in-state calls only 


Wyoming 

1(800)856-4398 



27 



1-800-MEDICARE (1-800-633-4227) 



SECTION 4: WHERE TO CALL FOR HELP 



Durable Medical Equipment Regional Carrier (DMERC): Call about bills for 
durable medical equipment and a list of approved suppliers of this equipment. 



If vou live in: 


Your DMERC is: 


i If vou live in: 


Your DMERC is: 


Illinois 


Adminastar 


Alaska 


Cigna Medicare 


Indiana 


Federal 


American Samoa 


1(800)899-7095 


Maryland 


1(800)270-2313 


Arizona 




Michigan 




California 


TTY/TDD: 


Minnesota 


TTY/TDD: 


Guam 


1(800)970-7494 


Ohio 


1(317)841-4677 


Hawaii 




Virginia 




Idaho 




Washington D.C. 




Iowa 




West Virginia 




Kansas 




Wisconsin 




Missouri 
Montana 
Nebraska 
Nevada 
North Dakota 








Northern Mariana Islands 






Oregon 








South Dakota 








Utah 

Washington 

Wyoming 




If vou live in: 


Your DMERC is: 


If vou live in: 


Your DMERC is: 


Alabama 


Palmetto 


Connecticut 


Blue Cross Blue i 


Arkansas 


Government 


Delaware 


Shield of Western 


Colorado 


Benefits 


Maine 


New York 


Florida 


Administration 


Massachusetts 


1(800)842-2052 


Georgia 


1(800)213-5452 


New Hampshire 




Kentucky 




New Jersey 


TTY/TDD: 


Louisiana 




New York 


1(800)842-9519 


Mississippi 




Pennsylvania 




New Mexico 




Rhode Island 




North Carolina 




Vermont 




Oklahoma 








Puerto Rico 








South Carolina 








Tennessee 








Texas 








Virgin Islands 









www.medicare.gov 



28 



SECTION 4: WHERE TO CALL FOR HELP 



Fiscal Intermediary: Call about Part A bills and services, hospital care, skilled nursing 
care, and fraud and abuse. Calls may be referred to another company that covers your claims. 





Alabama 

Mutual of Omaha, 
1(402)351-2860 


Arizona 

Blue Cross Blue Shield of 
Arizona, 

1(800)232-2345x4298 
TTY/TDD: 1(602)864-4823 


Colorado 

Trailblazer Health 
Enterprises, 
1(800)442-2620 
TTY/TDD: 1(800)516-6684 




Alaska 

Premera Blue Cross 

Medicare, 

1(425)670-1010 


Arkansas 

Blue Cross Blue Shield, 
1(877)356-2368 
TTY/TDD: 1(888)476-3009 


Connecticut 

Empire Medicare Services, 
1(800)442-8430 
TTY/TDD: 1(631)244-5101 


American Samoa 

Blue Cross of California, 
1(808)942-2400 

After December 1,2000 
United Government 
Services will replace Blue 
Cross of California. The 
phone number listed above 
will not change. 

29 -A 


California 

Blue Cross of California, 
1(805)383-2038 

After December 1,2000 
United Government 
Services will replace Blue 
Cross of California. The 
phone number listed above 
will not change. 

-800-MEDICARE (1-800-633-4227 


Delaware 

Empire Medicare Services, 
1(800)442-8430 
TTY/TDD: 1(631)244-5101 

) 



SECTION 4: WHERE TO CALL FOR HELP 

Fiscal Intermediary: Call about Part A bills and services, hospital care, skilled nursing 
care, and fraud and abuse. 



Florida 


Hawaii 


Indiana 




Blue Cross Blue Shield, 


Blue Cross of California, 


Adminastar Federal, 


1(904)355-8899 


1(808)942-2400 


1(800)622-4792 


TTY/TDD: 1(800)754-7820 


After December 1,2000 
United Government 
Services will replace Blue 
Cross of California. The 
phone number listed above 
will not change. 




Georgia 


Idaho 


Iowa 


Blue Cross Blue Shield, 


Medicare Northwest, 


Cahaba Health Benefits 


1(706)322-4082 


1(503)721-7000 


Administration, 


TTY/TDD: 1(706)571-5454 




1(515)471-7200 


B)l 


Guam 


Illinois 


Kansas 


1 


Blue Cross of California, 


Adminastar Federal, 


Blue Cross Blue Shield - 


KSy 


1(808)942-2400 


1(312)938-6266 


Part A, 

1(800)445-7170 

TTY/TDD: 1(800)430-8757 




After December 1,2000 








United Government 








Services will replace Blue 






^M>vH| 


Cross of California. The 








phone number listed above 








will not change. 









www.medicare.gov 



29 -B 



SECTION 4: WHERE TO CALL FOR HELP 

Fiscal Intermediary: Call about Part A bills and services, hospital care, skilled nursing 
care, and fraud and abuse. 



Kentucky 

Adminastar Federal, 
1(800)999-7608 
TTY/TDD: 1(502)329-8713 



Maryland 

Blue Cross Blue Shield of 

Maryland, 

1(800)655-1636 



Minnesota 

Noridian Mutual Insurance 
Company, 
1(800)330-5935 
TTY/TDD: 1(303)858-5903 



Louisiana 

Trispan Health Services, 
1(800)932-7644 
TTY/TDD: 1(601)939-5704 



Massachusetts 

Associated Hospital Service 
of Maine, 
1(888)896-4997 
TTY/TDD: 1(207)822-4646 



Mississippi 

Trispan Health Services, 
1(800)932-7644 
TTY/TDD: 1(601)939-5704 



Maine 

Associated Hospital Service 
of Maine, 
1(888)896-4997 
TTY/TDD: 1(207)822-4646 



Michigan 

United Government 

Services, 

1(313)225-8317 



Missouri 

Trispan Health Services, 
1(800)932-7644 
TTY/TDD: 1(601)939-5704 



29 -C 



800-MEDK ARE (1-800-633-4227) 



SECTION 4: WHERE TO CALL FOR HELP 

Fiscal Intermediary: Call about Part A bills and services, hospital care, skilled nursing 
care, and fraud and abuse. 



Montana 

Blue Cross Blue Shield, 
1(800)447-7828 x4086 
TTY/TDD: 1(800)637-8010 
x4086 


New Hampshire 

Anthem Blue Cross Blue 

Shield, 

1(800)522-8323 


New York 

Empire Medicare Services, 
1(800)442-8430 
TTY/TDD: 1(631)244-5101 




Nebraska 

Blue Cross Blue Shield, 
1(402)390-1850 


New Jersey 

Riverbend GBA, 
1(973)456-2112 


North Carolina 

Blue Cross Blue Shield, 
1(800)685-1512 in-state 
calls only 
TTY/TDD: 1(800)735-2962 


[oil 


Nevada 

Blue Cross of California, 
1(805)383-2038 

After December 1,2000 
United Government 
Services will replace Blue 
Cross of California. The 
phone number listed above 
will not change. 


New Mexico 

Trailblazer Health 
Enterprises, 
1(800)442-2620 
TTY/TDD: 1(800)516-6684 


North Dakota 

Noridian Mutual Insurance 
Company, 
1(800)247-2267 
TTY/TDD: 1(303)858-5903 



www.niedicare.gov 



29 -D 



SECTION 4: WHERE TO CALL FOR HELP 

Fiscal Intermediary: Call about Part A bills and services, hospital care, skilled nursing 
care, and fraud and abuse. 



Northern Mariana Islands 

Blue Cross of California, 
1(808)942-2400 

After December 1 , 2000 United Government 
Services will replace Blue Cross of California. 
The phone number listed above will not change. 



Puerto Rico 

Cooperativa De Seguros De Vida, 
1(787)758-9720 



Ohio 

Adminastar Federal, 
1(513)852-4314 



Rhode Island 

Blue Cross Blue Shield of Rhode Island, 

1(800)662-5170 

TTY/TDD: 1(888)239-3356 



Oklahoma 

Blue Cross Blue Shield, 
1(918)560-3367 



South Carolina 

Blue Cross Blue Shield of South Carolina, 
1(800)521-3761 in-state calls only 
TTY/TDD: 1(803)935-0147 



Oregon 

Medicare Northwest, 
1(503)721-7000 



South Dakota 

Cahaba Health Benefits Administration, 
1(515)471-7200 



Pennsylvania 

Veritus Medicare Services, 
1(800)853-1419 
TTY/TDD: 1(800)452-8086 



30 



Tennessee 

Riverbend Government Benefit 
Administrator, 
1(423)755-5955 
TTY/TDD: 1(423)763-3088 



1-800-MEDICARE (1-800-633-4227) 



SECTION 4: WHERE TO CALL FOR HELP 

Fiscal Intermediary: Call about Part A bills and services, hospital care, skilled nursing 
care, and fraud and abuse. 



Texas 

Trailblazer Health Enterprises, 
1(800)442-2620 
TTY/TDD: 1(800)516-6684 



Washington 

Premera Blue Cross Medicare, 
1(425)670-1010 



Utah 

Blue Cross Blue Shield, 
1(801)333-2410 
TTY/TDD: 1(800)346-4128 



Washington, D.C. 

Mutual of Omaha, 
1(402)351-2860 



Vermont 

Anthem Blue Cross Blue Shield, 
1(800)522-8323 



West Virginia 

United Government Services, 
1(540)985-3931 
TTY/TDD: 1(540)767-7103 



Virgin Islands 

Cooperativa De Seguros De Vida, 
1(787)758-9720 



Wisconsin 

United Government Services, 
1(414)224-4954 



Virginia 

United Government Services, 
1(540)985-3931 
TTY/TDD: 1(540)767-7103 



Wyoming 

Blue Cross Blue Shield, 
1(888)557-2301 



www.medicare.gov 



31 



SECTION 4: WHERE TO CALL FOR HELP 



Regional Home Health Intermediary (RHHI): Call about questions on home health 
care, hospice care, and fraud and abuse. 



If vou live in: 




Your RHHI is: 


Connecticut 




Associated Hospital Service of Maine, 


Maine 




1(888)896-4997 


Massachusetts 




TTY/TDD: 1(207)822-4646 


New Hampshire 




• 


Rhode Island 






Vermont 






If vou live in: 




Your RHHI is: 


Alaska 


Nevada 


Blue Cross of California Medicare, 


American Samoa 


Northern Mariana 


1(805)383-2990 


Arizona 


Islands 




California 


Oregon 




Guam 


Washington 




Idaho 






If vou live in: 




Your RHHI is: 


Hawaii 




Blue Cross of California Medicare, 



1(808)942-2400 



If vou live in: 




Your RHHI is: 


Colorado 


North Dakota 


Cahaba Health Benefits Administration, 


Delaware 


Pennsylvania 


1(515)471-7200 


Iowa 


South Dakota 




Kansas 


Utah 




Maryland 


Virginia 




Missouri 


Washington, D.C. 




Montana 


West Virginia 




Nebraska 


Wyoming 





32 



1 -800-M EDIC A RE ( 1 -800-633-4227) 



SECTION 4: WHERE TO CALL FOR HELP 



Regional Home Health Intermediary (RHHI): Call about questions on home health 
care, hospice care, and fraud and abuse. 



If you live in : 

Alabama 

Arkansas 

Florida 

Georgia 

Kentucky 

Louisiana 

Mississippi 

New Mexico 

Oklahoma 

South Carolina 

Texas 

Illinois 

Indiana 

North Carolina 

Ohio 

Tennessee 



Your RHHI is : 

Palmetto Government Benefits 
Administration, 
1(803)788-4660 
TTY/TDD: 1(803)935-0147 



If you live in : 



Your RHHI is: 



Michigan 
Minnesota 
New Jersey 
New York 
Puerto Rico 
Virgin Islands 
Wisconsin 



United Government Services, 
1(414)224-4954 



www.medicare.gov 



33 



SECTION 4: WHERE TO CALL FOR HELP 



Peer Review Organization (PRO): Call about quality of care concerns, filing an appeal 
or complaint, or for questions about your rights as a hospital patient. 





Alabama 

Alabama Quality Assurance 

Foundation, 

1(800)760-4550 


Arizona 

Health Services Advisory 
Group Company, 
1(800)359-9909 


Colorado 

Colorado Foundation for 
Medical Care, Inc., 
1(800)727-7086 
TTY/TDD: 1(303)695-3314 


Erl 


Alaska 

PRO West, 
1(800)445-6941 
TTY/TDD: 1(800)251-8890 


Arkansas 

Arkansas Foundation for 
Medical Care, Inc., 
1(800)272-5528 


Connecticut 

Qualidigm, 
1(800)553-7590 




American Samoa 

Mountain Pacific Quality 
Health Foundation, 
1(800)524-6550 


California 

California Medical Review, 
1(800)841-1602 
TTY/TDD: 1(800)881-5980 


Delaware 

Quality Insights of 
Delaware, 

1(800)422-8804 in-state 
calls only 

• 



34 



1-800-MEDICARE (1-800-633-4227) 



SECTION 4: WHERE TO CALL FOR HELP 



Peer Review Organization (PRO): Call about quality of care concerns, filing an appeal 
or complaint, or for questions about your rights as a hospital patient. 



Florida 

Florida Medical Quality 
Assurance, Inc., 
1(800)844-0795 

Georgia 

Georgia Medical Care 

Foundation, 

1(800)979-7217 


Hawaii 

Mountain Pacific Quality 
Health Foundation, 
1(800)524-6550 

Idaho 

PRO West, 
1(800)445-6941 
TTY/TDD: 1(800)251-8890 


Indiana 

Health Care Excel, Inc., 
1(800)288-1499 

Iowa 

Iowa Foundation for 
Medical Care, Inc., 
1(800)752-7014 


Krl 


Guam 

Mountain Pacific Quality 
Health Foundation, 
1(800)524-6550 


Illinois 

Illinois Foundation for 
Quality Health Care, 
1(800)647-8089 


Kansas 

The Kansas Foundation For 
Medical Care, Inc., 
1(800)432-0407 





www.medicare.gov 



35 



SECTION 4: WHERE TO CALL FOR HELP 



Peer Review Organization (PRO): Call about quality of care concerns, filing an appeal 
or complaint, or for questions about your rights as a hospital patient. 





Kentucky 

Health Care Excel, Inc., 
1(800)288-1499 


Maryland 

Delmarva Foundation for 
Medical Care, 
1(800)492-5811 


Minnesota 

Stratis Health, 
1(800)444-3423 




Louisiana 

Louisiana Health Care 
Review, Inc., 
1(800)433-4958 in-state 
calls only 


Massachusetts 

Massachusetts Peer Review 
Organization, Inc., 
1(800)252-5533 in-state 
calls only 


Mississippi 

Mississippi Foundation For 
Medical Care, Inc., 
1(800)844-0600 


Maine 

Northeast Health Care 
Quality Foundation, 
1(800)772-0151 in-state 
calls only 


Michigan 

Michigan Peer Review 
Organization, Inc., 
1(800)365-5899 


Missouri 

Missouri Patient Care 
Review Foundation, 
1(800)347-1016 



36 



1-800-MEDICARE (1-800-633-4227) 



SECTION 4: WHERE TO CALL FOR HELP 

Peer Review Organization (PRO): Call about quality of care concerns, filing an appeal 
or complaint, or for questions about your rights as a hospital patient. 



Montana 

Mountain Pacific Quality 
Health Foundation, 
1(800)497-8232 


New Hampshire 

Northeast Health Care 
Quality Foundation, 
1(800)772-0151 in-state 
calls only 


New York 
Island Peer Review 
Organization - IPRO, 
1(800)331-7767 


Nebraska 

Sunderbruch Corporation, 
1(800)247-3004 

Nevada 

Healthinsight, 
1(800)748-6773 


New Jersey 

The Peer Review 

Organization of New Jersey, 

Inc., 

1(800)624-4557 in-state 

calls only 

New Mexico 

New Mexico Medical 
Review Association, 
1(800)279-6824 


North Carolina 

Medical Review Of North 
Carolina, Inc., 
1(800)722-0468 

North Dakota 

North Dakota Health Care 
Review, Inc., 
1(800)472-2902 in-state 
calls only 



www.mcdicar6.gov 



37 



SECTION 4: WHERE TO CALL FOR HELP 



Peer Review Organization (PRO): Call about quality of care concerns, filing an appeal 
or complaint, or for questions about your rights as a hospital patient. 





Northern Mariana Islands 


Puerto Rico 


Mountain Pacific Quality Health 


Quality Improvement Professional 


Foundation, 


Research Organization, 


1(800)524-6550 


1(800)981-5062 in-state calls only 


Ohio 


Rhode Island 


KePRO, Inc., 


Rhode Island Quality Partners, Inc., 


1(800)589-7337 


1(800)662-5028 


Oklahoma 


South Carolina 


Oklahoma Foundation For Medical 


Carolina Medical Review, 


Quality, Inc., 


1(800)922-3089 in-state calls only 


1(800)522-3414 in-state calls only 




Pjh Oregon 


South Dakota 


1*)1 


Oregon Medical Professional Review 


South Dakota Foundation for Medical 




Organization, 


Care, Inc., 


m 


1(800)344-4354 


1(800)658-2285 




Pennsylvania 


Tennessee 




Keystone Peer Review Organization - 


Mid South Foundation For Medical Care, 


IH**^B 


KEPRO, 


Inc., 




1(800)322-1914 


1(800)489-4633 



38 



1-800-MEDICARE (1-800-633-4227) 



SECTION 4: WHERE TO CALL FOR HELP 



Peer Review Organization (PRO): Call about quality of care concerns, filing an appeal 
or complaint, or for questions about your rights as a hospital patient. 



Texas 

Texas Medical Foundation, 
1(800)725-8315 
TTY/TDD: 1(800)725-8339 


Washington 

PRO West, 
1(800)445-6941 
TTY/TDD: 1(800)251-8890 




Utah 

Healthinsight, 
1(800)274-2290 


Washington, D.C. 

Delmarva Foundation for Medical Care, 
1(800)645-0011 




Vermont 

Northeast Health Care Quality Foundation, 
1(800)772-0151 in-state calls only 


West Virginia 

West Virginia Medical Institute, Inc., 
1(800)642-8686x2266 




Virgin Islands 

Virgin Island Medical Institute, Inc., 
1(340)712-2400 


Wisconsin 

Medistar, 
1(800)362-2320 


5)1 


Virginia 

Virginia Health Quality Center, 
1(800)545-3814 in-state calls only 
TTY/TDD: 1(800)828-1140 


Wyoming 

Mountain Pacific Quality Health Foundation, 
1(800)497-8232 



wwvv.medicare.gov 



39 



SECTION 4: WHERE TO CALL FOR HELP 



State Insurance Department: Call with questions about the Medigap policies sold in 
your area and any insurance-related problems. 





Alabama 

1(800)433-3966 in-state calls only 


Illinois 

1(312)814-2427 




Alaska 

1(800)467-8725 in-state calls only 


Indiana 

1(800)622-4461 in-state calls only 


American Samoa 

1(808)586-2790 


Iowa 

1(515)281-5705 


Arizona 

1(800)325-2548 in-state calls only 


Kansas 

1(800)432-2484 in-state calls only 


Arkansas 

1(800)224-6330 


Kentucky 

1(800)595-6053 


California 

1(800)927-4357 in-state calls only 


Louisiana 

1(800)259-5301 in-state calls only 


Colorado 

1(800)930-3745 in-state calls only 


Maine 

1(800)300-5000 in-state calls only 


Connecticut 

1(800)203-3447 in-state calls only 


Maryland 

1(800)492-6116 


Delaware 

1(800)282-861 1 in-state calls only 


Massachusetts 

1(617)521-7794 


Erl 


Florida 

1(800)342-2762 in-state calls only 


Michigan 

1(877)999-6442 


Ha«H 


Georgia 

1(800)656-2298 in-state calls only 


Minnesota 

1(800)657-3602 in-state calls only 






Guam 

1(808)586-2790 


Mississippi 

1(800)562-2957 in-state calls only 




^■**fl 


Hawaii 

1(808)586-2790 


Missouri 

1(800)726-7390 


Hr«H 


Idaho 

1(800)721-3272 in-state calls only 

40 1-800-MEDlCAR] 


Montana 

1(800)332-6148 in-state calls only 

E (1-800-633-4227) 





SECTION 4: WHERE TO CALL FOR HELP 

State Insurance Department: Call with questions about the Medigap policies sold in 
your area and any insurance-related problems. 



Nebraska 

1(800)234-7119 


Rhode Island 

1(401)222-2223 




Nevada 

1(800)992-0900 in-state calls only 


South Carolina 

1(800)768-3467 in-state calls only 




New Hampshire 

1(800)852-3416 


South Dakota 

1(605)773-3563 




New Jersey 

1(609)292-5360 


Tennessee 

1(800)525-2816 




New Mexico 

1(800)947-4722 in-state calls only 


Texas 

1(800)252-3439 




New York 

1(800)342-3736 in-state calls only 


Utah 

1(800)439-3805 in-state calls only 




North Carolina 

1(800)443-9354 in-state calls only 


Vermont 

1(800)631-7788 in-state calls only 




North Dakota 

1(800)247-0560 in-state calls only 


Virgin Islands 

1(340)774-7166 




Northern Mariana Islands 

1(808)586-2790 


Virginia 

1(800)552-7945 in-state calls only 




Ohio 

1(800)686-1578 in-state calls only 


Washington 

1(800)397-4422 


Sri 

9h v A9 


Oklahoma 

1(800)522-0071 in-state calls only 


Washington, D.C. 

1(202)727-8000 


H 


Oregon 

1(800)722-4134 in-state calls only 


West Virginia 

1(800)642-9004 in-state calls only 




Pennsylvania 

1(877)881-6388 in-state calls only 


Wisconsin 

1(800)236-8517 in-state calls only 


^HV^| 


Puerto Rico 

1(787)722-8686 


Wyoming 

1(800)438-5768 in-state calls only 


Ht^*H 



www.medicare.gov 



41 



SECTION 4: WHERE TO CALL FOR HELP 



State Medical Assistance Office: Call about programs to help pay medical bills for 
people with low incomes. 





Alabama 

1(800)362-1504 in-state calls only 


Illinois 

1(800)252-8635 in-state calls only 






Alaska 

1(800)21 1-7470 in-state calls only 


Indiana 

1(317)232-4966 




American Samoa 

1(808)587-3521 


Iowa 

1(800)972-2017 




Arizona 

1(800)523-0231 out-of-state calls only 
1(800)654-8713 in-state calls only 


Kansas 

1(800)766-9012 




Arkansas 

1(800)482-8988 


Kentucky 

1(800)635-2570 




California 

1(800)952-5253 


Louisiana 

1(888)342-6207 in-state calls only 




Colorado 

1(800)221-3943 


Maine 

1(800)452-1926 in-state calls only 




Connecticut 

1(800)842-1508 in-state calls only 


Maryland 

1(800)492-5231 




Delaware 

1(800)372-2022 in-state calls only 


Massachusetts 

1(800)841-2900 


Florida 

1(850)488-3560 


Michigan 

1(800)642-3195 in-state calls only 




Georgia 

1(800)766-4456 in-state calls only 


Minnesota 

1(800)657-3659 


Guam 

Number Not Available 


Mississippi 

1(800)421-2408 in-state calls only 


Hawaii 

1(808)587-3521 


Missouri 

1(800)392-2161 


Idaho 

1(877)200-5441 

42 1-800-MEDICAR1 


Montana 

1(800)362-8312 

E (1-800-633-4227) 





SECTION 4: WHERE TO CALL FOR HELP 



State Medical Assistance Office: Call about programs to help pay medical bills for 
people with low incomes. 



Nebraska 

1(800)430-3244 


Rhode Island 

1(401)222-7000 




Nevada 

1(800)992-0900 


South Carolina 

1(803)898-2500 




New Hampshire 

1(800)852-3345 in-state calls only 


South Dakota 

1(605)773-3495 




New Jersey 

1(800)356-1561 in-state calls only 


Tennessee 

1(800)342-3145 




New Mexico 

1(888)997-2583 in-state calls only 


Texas 

1(800)252-8263 




New York 

1(518)486-9057 

North Carolina 

1(800)662-7030 in-state calls only 

North Dakota 

1(800)755-2604 

Northern Mariana Islands 

1(808)587-3521 


Utah 

1(800)662-9651 in-state calls only 

Vermont 

1(800)250-8427 

Virgin Islands 

1(787)250-7429 

Virginia 

1(804)786-7933 




Ohio 

1(800)324-8680 


Washington 

1(800)562-3022 


Oklahoma 

1(800)522-0310 in-state calls only 


Washington, D.C. 

1(202)727-0725 


Oregon 

1(800)282-8096 in-state calls only 


West Virginia 

1(304)558-1700 


Pennsylvania 

1(800)692-7462 in-state calls only 


Wisconsin 

1(800)362-3002 


Puerto Rico 

1(787)250-7429 


Wyoming 

1(800)251-1269 



www.medicare.gov 



43 



SECTION 4: WHERE TO CALL FOR HELP 



Health Care Financing Administration (HCFA) Regional Offices: Call for 
information about local seminars and health fairs on Medicare health plan choices, or to report 
a complaint directly to HCFA. 



1(617)565-1232 

Connecticut, Maine, Massachusetts, 
New Hampshire, Rhode Island, Vermont 



1(214)767-6401 

Arkansas, Louisiana, New Mexico, 
Oklahoma, Texas 



1(212)264-3657 

New Jersey, New York, Puerto Rico, 
Virgin Islands 



1(816)426-2866 

Iowa, Kansas, Missouri, Nebraska 



1(215)861-4226 

Delaware, Maryland, Pennsylvania, 
Virginia, Washington, D.C., West Virginia 



1(303)844-4024 

Colorado, Montana, North Dakota, 
South Dakota, Utah, Wyoming 



1(404)562-7500 

Alabama, Florida, Georgia, Kentucky, 

Mississippi, North Carolina, South 

Carolina, Tennessee 



1(415)744-3602 

American Samoa, Arizona, California, 

Guam, Hawaii, Nevada, Northern Mariana 

Islands 



1(312)353-7180 

Illinois, Indiana, Michigan, Minnesota, 
Ohio, Wisconsin 



1(206)615-2354 

Alaska, Idaho, Oregon, Washington 



Office for Civil Rights: Call for information about submitting a complaint about 
discrimination. 



• You can call toll-free 1-800-368-1019, TTY/TDD: 1-800-537-7697* (for the hearing and 
speech impaired). 

• Look on the Internet at www.medicare.gov to get the local number for your state. Click on 
Helpful Contacts. 

• Alaska, Idaho, Washington TTY/TDD: 1-800-362-1710 (for the hearing and speech 
impaired). 

44 1-800-MEDICARE (1-800-633-4227) 



SECTION 5: YOUR MEDICARE RIGHTS AND PROTECTIONS 



Your Medicare Patient Rights 



Information: 



Emergency Care: 



Appeals: 



Treatment Choices: 



Privacy: 



If you have Medicare, you have certain guaranteed rights. You 
have them whether you are in the Original Medicare Plan, a 
Medicare managed care plan, or a Private Fee-for-Service 
plan 

You have the right to receive easy-to-understand information 
about Medicare, what costs it pays, and how much you have to 
pay. And you have a right to know what to do if you have to 
file a complaint. 

You have the right to get emergency care when and where you 
need it. You don't need an OK from your health plan. If you 
think your health is in serious danger because you have severe 
pain, a bad injury, sudden illness, or an illness quickly getting 
much worse, you can get emergency care anywhere in the 
United States. 

You have the right to file an appeal if Medicare does not pay 
for a covered service you have been given, or if your health 
plan does not give you a service that you believe should be 
provided (see pages 46-47). 

You have the right to know all your treatment options from 
your health care provider in language that is clear to you, and 
in a language that you understand. 

You have the right to have any personal information that 
Medicare collects kept private. Medicare may collect 
information about you as part of its regular business, such as 
paying your bills. When Medicare asks for this kind of 
information, we must tell you that the law lets us collect it, 
why it is being collected, whether it is required or optional, 
what happens if you don't give the information, and how it will 
be used. If you want this information call 1-800-MEDICARE 
(1-800-633-4227) and ask for more information about how 
Medicare uses personal information. 



www.medicare.gov 



45 



SECTION 5: YOUR MEDICARE RIGHTS AND PROTECTIONS 



Your rights 
in a 

Medicare 
Managed 
Care Plan 



/ 



• You have a right to choose a women's health specialist 
from your plan's list of doctors for routine and preventive 
health care services. 

• If you have a complex or serious medical condition, you 
have a right to a treatment plan from your doctor which 
gives you enough visits to a specialist to deal with your 
needs. 

• Medicare managed care plans cannot have rules that stop a 
doctor from telling you everything you need to know about 
your health care, including treatment options. 

• You have a right to know how your plan pays its doctors. If 
you want to know how your plan pays its doctors, the plan 
must tell you in writing. You also have the right to know 
whether your doctor owns all or part of a health care 
facility. For example, if you are referred for a blood test to 
a lab that he or she owns. 

• If you have concerns or problems with your plan which are 
not about payment or service requests, you have a right to 
file a complaint. This type of complaint is called a 
grievance. For example, if you believe your plan's hours of 
operation should be different, you can file a grievance. If 
you believe you are not getting a high quality of care, you 
may file a grievance with either your plan or with the Peer 
Review Organization (PRO) in your State (see pages 
34-39). 



Your Medicare 
Appeal Rights 



You have the right to appeal any decision about your 
Medicare services. This is true whether you are in the 
Original Medicare Plan or another Medicare health plan. If 
Medicare does not pay for an item or service you have been 
given, or if you are not given an item or service you think 
you should get, you can appeal. 



46 



1-800-MEDICARE (1-800-633-4227) 



SECTION 5: YOUR MEDICARE RIGHTS AND PROTECTIONS 



Your Appeal 
Rights In The 
Original Medicare 
Plan ► 



Appeal Rights In a 
Medicare Managed 
Care Plan or 
Private Fee-for- 
Service Plan ► 



You are Protected 
from Unexpected 
Bills ► 



If you are in the Original Medicare Plan, you can file an 
appeal if you think Medicare should have paid for, or did not 
pay enough for, an item or service you received. If you file 
an appeal, ask your doctor or provider for any information 
related to the bill that might help your case. Your appeal 
rights are on the back of the Explanation of Medicare 
Benefits or Medicare Summary Notice that is mailed to you 
from a company that handles bills for Medicare. The notice 
will also tell you why Medicare didn't pay your bill and how 
you can appeal. 

If you are in a Medicare managed care plan or Private Fee- 
for-Service plan, you can file an appeal if your plan will not 
pay for, does not allow, or stops a service that you think 
should be covered or provided. If you think your health 
could be seriously harmed by waiting for a decision about a 
service, ask the plan for a fast decision. The plan must reach 
a decision within 72 hours. 

The plan must tell you in writing how to appeal. After you 
file an appeal, the plan will review its decision. Then, if 
your plan does not decide in your favor, an independent 
organization that works for Medicare, not for the plan, 
reviews the appeal. See your plan's membership materials or 
contact your plan for details about your Medicare appeal 
rights. You may also call 1-800-MEDICARE 
(1-800-633-4227) to ask for more information about your 
rights during an appeal. 

A doctor or supplier might give you a notice that says 
Medicare probably (or certainly) will not pay for a service. 
If you still want to get the service, you will be asked to sign 
an agreement that you will pay for the service yourself if 
Medicare does not pay for it. This is called an Advance 
Beneficiary Notice. Advance Beneficiary Notices are used 
in the Original Medicare Plan, but not in Medicare managed 
care plans. 

If you aren't sure if Medicare was billed for the services that 
you got, write to the health care provider and ask for an 
itemized statement. This statement will list each Medicare 
item or service you got from your doctor, hospital, or any 



www.medicare.gov 



47 



SECTION 5: YOUR MEDICARE RIGHTS AND PROTECTIONS 



You are 
Protected from 
Discrimination ► 



You are Protected 
When You are in the 
Hospital ► 



other health supplier. You should get it within 30 days. Also, 
you can check your Explanation of Medicare Benefits or 
Medicare Summary Notice to see if the service was billed to 
Medicare. 

If you are in a Private Fee-for-Service plan, call your plan 
to find out if a service or supply will be covered. The plan 
must tell you if you ask. 

Every company or agency that works with Medicare must 
obey the law. You cannot be treated differently because of 
your race, color, national origin, disability, age, or sex under 
certain conditions. If you think that you have not been 
treated fairly for any of these reasons, call the Office for 
Civil Rights in your State (see page 44). 

If you are admitted to a Medicare participating hospital, you 
should be given a copy of An Important Message About 
Medicare Rights: Admission, Discharge, and Appeals. It 
explains your rights as a hospital patient. If you are not 
given one, ask for it. If you are in a Private Fee-for-Service 
plan, call your plan to find out what your protections are. 
They may be different. 



The Message tells you: 

• You have the right to get all of the hospital care that you 
need, and any follow-up care after you leave the hospital. 

• What to do if you think the hospital is making you leave too 
soon. 

If you have questions about this, call your Peer Review 
Organization (PRO). Their number is on the copy of An 
Important Message About Medicare Rights: Admission, 
Discharge, and Appeals brochure that you got when you 
were admitted to the hospital. You may be able to stay in the 
hospital at no charge while they review your case. The 
hospital cannot force you to leave before the PRO makes a 
decision. 



48 



1-800-MEDICARE (1-800-633-4227) 



SECTION 5: YOUR MEDICARE RIGHTS AND PROTECTIONS 



You are Protected 
in a Skilled 
Nursing Facility ► 



A skilled nursing facility (SNF) is a Medicare-certified 
facility that has the staff and equipment to give skilled 
nursing care or skilled rehabilitation services and other 
related health services. You must meet certain conditions for 
skilled nursing facility care coverage, such as a 3-day 
hospital stay, before you are admitted. Some nursing homes 
give this type of skilled care. 

For your protection: 

• The SNF cannot make you pay anything to be admitted 
unless it is clear that Medicare does not cover the cost of 
services; 

• You must be told right away if the SNF decides that you do 
not need the level of skilled care covered by Medicare. If 
you disagree with this decision, you may ask that the SNF 
submit a "demand bill" to Medicare for an official 
decision. 

The SNF must submit the demand bill and cannot make you 
pay a deposit for services that Medicare may not cover until 
Medicare gives its decision. 

You must pay any coinsurance due while the demand bill is 
being processed, and for the services not covered by 
Medicare. If you are in a Medicare managed care plan or 
Private Fee-for-Service plan, call your plan for information 
about Skilled Nursing Facility coverage. 

If you have questions about SNF care, call your Fiscal 
Intermediary (see pages 29A-31). You may also call 
1-800-MEDICARE (1-800-633-4227) and ask for a copy of 
Medicare Coverage of Skilled Nursing Facility Care. 



You are Protected 
When Your Home 
Health Care Ends ► 



Home health care agencies must give you a notice that 
explains why and when they think Medicare will stop paying 
for your home health care. If you think you still need home 
health care, and you think Medicare should keep paying, you 
can ask Medicare for an official decision. 



www.medicarc.gov 



49 



SECTION 5: YOUR MEDICARE RIGHTS AND PROTECTIONS 



To get an official decision, you should: 



Keep getting home health care if you think you need it 
Ask how much it will cost. You should talk to your doctor 
and family about this. 

Pay the home health agency for these services. 

Ask the home health agency to send your claim to 
Medicare so that Medicare will decide if it will pay. 



If Medicare decides to pay, you will get back all of your 
payments, except for any coinsurance for durable medical 
equipment. If Medicare decides not to pay, you will get a 
letter that tells you how to appeal. You can always get home 
health care if you want to pay for it yourself. If you have 
questions about home health care in the Original Medicare 
Plan, call your Regional Home Health Intermediary (see 
pages 32-33). If you have questions about home health care 
in a Medicare managed care plan or Private Fee-for-Service 
plan, call your plan. You may also call 1-800-MEDICARE 
(1-800-633-4227) and ask for a free copy of Medicare Home 
Health Services. 






Medigap 

Policy 

Protections 



You may have the right to buy a Medigap policy, even if you 
are in poor health. For more information, see page 57. 



You Can Help 
Watch Over 
Spending in 
Medicare 



Most doctors and health care providers who work with 
Medicare are honest. There are a few who are not honest. We 
are working very hard with other government agencies to 
protect the Medicare program. 



50 



1-800-MEDICARE (1-800-633-4227) 



SECTION 5: YOUR MEDICARE RIGHTS AND PROTECTIONS 



What you can do 
to watch over 
spending in 
Medicare ► 



With help from the honest health care providers, law 
enforcement, and you, Medicare is solving this problem. 
Medicare has sent some dishonest providers to jail. Some 
providers have left the Medicare program. These actions are 
saving money for taxpayers and protecting Medicare for the 
future. 

You can help protect Medicare by: 

• Reviewing all payment notices from Medicare for errors. 

• Making sure Medicare was not billed for health care 
services or medical supplies and equipment you did not 
get. 

• Not giving your Medicare claim number (on your 
Medicare card) to anyone, except your doctor or other 
Medicare health professionals. You should not send these 
numbers over the Internet. 

• Not letting anyone, except appropriate medical health 
professionals, review your medical records. 



How to report 
errors and 
concerns ► 



What else can I do 
to fight fraud? 



If you see a charge on your payment notice that may be 
wrong, call the health care provider and ask about it. If you 
think that a provider may be cheating or abusing Medicare, 
call the Medicare Carrier or Fiscal Intermediary that sent 
you the notice. Their phone number is printed on the front of 
the notice. 

You can also call the Inspector General's hotline to report 
Medicare fraud. The hotline number is 1-800-HHS-TIPS 
(1-800-447-8477). Or, send a note to htips@os.dhhs.gov by 
e-mail. Medicare will not use your name if you ask that it 
not be used. 

Call your regional U. S. Administration on Aging Office and 
ask about programs in your community that train volunteers 
to detect and report fraud. Call 1-800-MEDICARE 
(1-800-633-4227) and ask for a free copy of the Medicare 
Fraud and Abuse Fact Sheet. You can also look on the 
Internet at www.medicare.gov to read or print this fact sheet. 



www. medic a re. gov 



51 



SECTION 6: QUESTIONS AND ANSWERS 

Medicare Questions and Answers 

On pages 52-65 are frequently asked Medicare questions and answers. They are grouped 
as follows: 

Ql - Q10 General Medicare questions, like a new Medicare card, address changes, 
Part B enrollment, travel, prescription drugs, Medicaid, and Private 
Contracts (pages 52-55). 

Ql 1 - Q12 Other general questions about the Original Medicare Plan (page 56). 

Q13 - Q16 Questions about Medigap (supplement insurance that helps fill "gaps" in 
Original Medicare Plan coverage) (pages 57-60). 

Q17 - Q24 Other general questions about Medicare managed care plans (like an HMO) 
or Private Fee-for-Service plans (pages 60-62). 

Q25 - Q30 Questions about mental health, nursing home, and long-term care (pages 
63-65). 

General Medicare Questions and Answers 



Ql : How do I get a new 

red, white, and blue 
Medicare card? 



A: To get a new Medicare card, call the Social Security 
Administration at 1-800-772-1213. They will send you 
a new card. If you get benefits from the Railroad 
Retirement Board, call your local RRB office or 
1-800-808-0772. 



Q2: My copy of 
Medicare & You was 
sent to the wrong 
address. How do I 
change my address? 



A: If you need to change your address, call the Social 

Security Administration at 1-800-772-1213, or call your 
local Social Security office. They will make the change 
for you. If you get benefits from the Railroad 
Retirement Board, call your local RRB office or 
1-800-808-0772. 



Q3: Why aren't the 
Medicare premium and 
coinsurance rates for 
2001 in this handbook? 



52 



A: The law says Medicare must send you this handbook by 
October each year, in time for the November period when 
most plans are required to accept new members. New 
Medicare premium and coinsurance rates were not 
available at the time this handbook was printed. If you get 
Social Security or Railroad Retirement benefits, new rates 
will be sent to you with your cost of living adjustment 
notice. You can also get the new rates after December 1, 
2000 by calling 1-800-MEDIC ARE (1-800-633-4227), or 
look at www.medicare.gov on the Internet. 
1-800-MEDIC A RE (1-800-633-4227) 



SECTION 6: QUESTIONS AND ANSWERS 



Q4: What if I didn't 
sign up for Part B when 
I first became eligible? 



A: If you did not take Part B when you were first eligible 
for Medicare at age 65, you may sign up during a 
General Enrollment Period. This period runs from 
January 1 through March 31 of each year. Remember, 
the cost of Part B may go up 10% for each 12-month 
period that you could have had Part B but did not 
take it, except in special cases (see below). You will 
have to pay this extra 10% for the rest of your life. 

You can sign up for Part B at your local Social Security 
office. If you get benefits from the Railroad Retirement 
Board, you can sign up at your local RRB office. Your 
Part B coverage will start on July 1 of that year. 



Q5: How do I sign up 
for Part B if I or my 
spouse continued to 
work and had group 
health plan coverage 
through my or my 
spouse's employer or 
union after I first 
became eligible? 



A: If you didn't take Part B when you were first eligible 
because you or your spouse was working and had group 
health coverage through your or your spouse's employer 
or union, you can sign up for Part B during a Special 
Enrollment Period. 

The Special Enrollment Periods when you can sign 
up are: 

1. Anytime you are still covered by the employer or union 
group health plan, through your or your spouse's current 
or active employment, or 

2. During the 8 months following the month when the 
employer or union group plan coverage ends, or when 
the employment ends (whichever is first). 

If you are disabled and working (or you have coverage 
from a working family member), the Special Enrollment 
Period rules also apply. 

Most people who sign up for Part B during a Special 
Enrollment Period do not pay higher premiums. 
However, if you are eligible, but do not sign up during 
the Special Enrollment Period, the cost of Part B may go 
up. 



www.medicare.gov 



53 



SECTION 6: QUESTIONS AND ANSWERS 



Q5: Special Enrollment 
Period (continued) 



For more information about, or to sign up for Medicare 
Part B, call the Social Security Administration at 1-800- 
772-1213, or call your local Social Security office. If 
you get benefits from the Railroad Retirement Board, 
call your local RRB office or 1-800-808-0772. 



Q6: Does Medicare 
cover me when I travel 
outside of the United 
States? 



A: The Original Medicare Plan generally does not cover 
care outside the United States, but some Medicare 
managed care plans, Private Fee-for-Service plans, and 
Medigap policies do. Check your insurance coverage 
before you travel outside the country. 



Q7: Does Medicare 
pay for prescription 
drugs? 



A: The Original Medicare Plan does not cover prescription 
drugs except in a few cases, like certain cancer drugs. 
Many Medicare managed care plans cover prescription 
drugs, up to certain dollar limits (sometimes for an 
extra cost). Some Medigap policies also cover 
prescription drugs. 



Q8: If I have Medicare 
and Medicaid, who will 
pay my health care bills 
first? 



For services that Medicare covers, your bill should 
always be sent to Medicare first. The part of the bill that 
Medicare does not pay will then be sent to your state 
Medicaid program for further payment. 



Q9: Are there any times 
when Medicare would 
pay second? 



A: Sometimes your other insurance pays your health care 
bills first and Medicare pays second. This is called 
Medicare Secondary Payer. Other insurance that may 
have to pay first includes: employer group health plan 
insurance under certain conditions, no-fault insurance, 
any liability insurance, black lung benefits, and workers' 
compensation. It is important that you tell your doctor 
or hospital that you have other insurance so they will 
know how to handle your bills correctly. If you have 
questions about who pays first, call the Coordination of 
Benefits Contractor (see page 24). For more 
information, call 1-800-MEDICARE (1-800-633-4227) 
and ask for a copy of Medicare and Other Health 
Benefits: Your Guide to Who Pays First. 



54 



1-800-MEDICARE (1-800-633-4227) 



SECTION 6: QUESTIONS AND ANSWERS 



Q10: What is a "Private A: A Private Contract is an agreement between you and a 
Contract," and how does doctor who has decided not to give services through the 

it work? Medicare program. If you sign a private contract with 

your doctor: 

• No Medicare payment will be made for the services 
you get from this doctor. 

• You will have to pay whatever this doctor or provider 
charges you (the limiting charge will not apply). 

• Medicare health plans (like managed care plans and 
Private Fec-for-Service plans) will not pay for these 
services. 

• No claim should be submitted, and Medicare will not 
pay if one is submitted. 

• Your Medigap policy, if you have one, will not pay 
anything for this service. Call your Medigap insurance 
company if you have any questions before you get the 
service. 

• Many other insurance plans will not pay for the service 
either. 

The private contract only applies to the services you get 
from the doctor who asked you to sign it. You cannot be 
asked to sign a private contract in an emergency or 
urgent health situation. You may want to talk with 
someone in your State Health Insurance Assistance 
Program before signing a private contract (see pages 
26-27). You can also call 1-800-MEDICARE 
(1-800-633-4227) and ask for information on private 
contracts. 

You are always free to get non-covered services on your 
own if you choose to pay for these services yourself. In 
this case, you do not have to sign a private contract and 
your doctor does not have to stop giving services 
through Medicare. 



www.medicarc.gov 55 



SECTION 6: QUESTIONS AND ANSWERS 



Original Medicare Plan Questions and Answers: 



Qll: How are my bills 
paid in the Original 
Medicare Plan? 



A: When you get services covered by the Original Medicare 
Plan, your provider sends the bill to a private company 
that handles bills for Medicare. The Fiscal Intermediary 
pays bills for Part A services (see pages 29A-31) and the 
Medicare Carrier pays bills for Part B services (see 
pages 25A-F). After they process the bill, you will get an 
Explanation of Medicare Benefits or a Medicare 
Summary Notice. Please check this payment notice to be 
sure you got all the services, medical supplies, or 
equipment that Medicare was billed for. If you have any 
questions about bills or services listed on the payment 
notice, call the provider and ask about it. If you disagree 
with what is covered or paid, you have the right to file 
an appeal (see page 46). If you think the provider is 
being dishonest, see page 50. 



Q12: What is 
"assignment" in the 
Original Medicare Plan 
and why is it important? 



A: Assignment is an agreement between Medicare and 
doctors and suppliers of health care equipment and 
supplies (like wheelchairs, oxygen, braces, and ostomy 
supplies). Doctors and suppliers who agree to accept 
assignment accept the Medicare-approved amount as 
payment in full. You pay the coinsurance and deductible 
amounts. If assignment is not accepted, charges are often 
higher. This means you may pay more. There is a limit 
on the amount your doctor can bill you. Ambulance 
suppliers and durable medical equipment suppliers that 
do not take assignment can charge you any amount. You 
are responsible to pay their full charges. Medicare will 
reimburse you later for its share of the bill. For more 
information about assignment, call 1-800-MEDICARE 
(1-800-633-4227) to get a free copy of Does Your Doctor 
or Supplier Accept Assignment? 



56 



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SECTION 6: QUESTIONS AND ANSWERS 



Medigap Questions and Answers: 



Q13: Do I need to buy a 
Medigap policy? 



A: Medigap policies help pay health care costs only if you 
have the Original Medicare Plan. Whether you need a 
Medigap policy is a decision that only you can make. 
Depending on your health care needs and finances, you 
may want to continue your employee or retiree coverage, 
or join a Medicare managed care plan, or a Private Fee- 
for-Service plan. 

You do not need to buy a Medigap policy if you are in a: 

• Medicare managed care plan 

• Private Fee-for-Service plan 

In fact, it may be illegal for anyone to sell you a 
Medigap policy if they know you are in one of these 
health plans. If you have Medicaid, it is generally illegal 
for an insurance company to sell you a Medigap policy. 
For more information, call 1-800-MEDICARE 
(1-800-633-4227) and ask for a free copy of the Guide to 
Health Insurance for People with Medicare. 



Q14: When is the best 
time to buy a Medigap 
policy? 



Note: If you are under age 
65 and disabled or have 
End-Stage Renal Disease 
(ESRD), you may not have 
an open enrollment period 
until you turn 65. However, 
in some states you may 
have other options, such as 
the right to buy the same 
Medigap policies that are 
sold to people under age 65. 



A: The best time to buy a Medigap policy is during your 
Medigap open enrollment period. Your Medigap open 
enrollment period lasts for 6 months. It begins on the 
first day of the month in which you are both age 65 or 
older and enrolled in Medicare Part B. 

During this period, an insurance company cannot deny 
you insurance coverage, place conditions on a policy 
(like making you wait for coverage to start), or change 
the price of a policy because of past or present health 
problems. 

Important: If you don't buy a Medigap policy during 
your open enrollment period, you may not be able to buy 
the one you want, or you may be charged more for the 
policy. In addition, if you drop your Medigap policy, you 
may not be able to get it back. 



www.medicare.gov 



57 



SECTION 6: QUESTIONS AND ANSWERS 



Medigap (Q14 continued) For more information: 



• Call your State Health Insurance Assistance Program 
(see pages 26-27). 

• Call 1-800-MEDICARE (1-800-633-4227) and ask for 
a free copy of the 2000 Guide to Health Insurance for 
People with Medicare. 

Note: If you are age 65 or older and have health 
coverage through an employer or union based on your or 
your spouse's current or active employment, you may 
want to wait to enroll in Medicare Part B and delay your 
Medigap open enrollment period (see page 53). 



Q15: What situations 
give me the right to buy 
a Medigap policy after 
my Medigap open 
enrollment period ends? 



A: There are certain situations involving health coverage 
changes when you may have the right to buy a Medigap 
policy after your Medigap open enrollment period ends. 
These are called Medigap protections because insurance 
companies are required by law to issue you a policy. For 
example: 

• Your Medicare managed care plan or Private Fee-for- 
Service plan is leaving the Medicare program or stops 
giving care in your area. 

• You move outside your Medicare managed care plan or 
Private Fee-for-Service plan's service area. 

• You leave your Medicare managed care plan or Private 
Fee-for-Service plan because it failed to meet its 
contract obligations to you (for example, the marketing 
material was misleading or quality standards were not 
met). 

• You are in an employer group health plan that 
supplements or pays some of the costs not paid by 
Medicare, and the plan ends your coverage. 

• Your health coverage (like a Medicare managed care 
plan, Private Fee-for-Service plan, employer group 



58 



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SECTION 6: QUESTIONS AND ANSWERS 



Medigap (Q15 continued) health plan that supplemented or paid some of the costs 

not paid for by Medicare, Medicare SELECT policy, 
Program of All-inclusive Care for the Elderly (PACE), 
or Medicare managed care demonstration project) ends 
through no fault of your own. For example, the 
company goes bankrupt. 

• You dropped your Medigap policy to join a Medicare 
managed care plan or Private Fee-for-Service plan, or 
buy a Medicare SELECT policy for the first time, and 
then leave that plan or policy within one year after 
joining. 

• You joined a Medicare health plan (like a Medicare 
managed care plan with a Medicare + Choice contract 
or Private Fee-for-Service plan) when you first became 
eligible for Medicare at age 65, and within one year of 
joining, you decided to leave the Medicare health plan. 

In these situations, the Medigap insurance company 
can't deny you insurance, place conditions on a policy, 
or charge you more for a policy because of past or 
present health problems. If you think any of these 
situations apply to you, call your State Health 
Insurance Assistance Program (see pages 26-27) to 
make sure that you qualify and to find out which of the 
Medigap policies you can buy. If you are denied 
Medigap coverage, you should call your State 
Insurance Department (see pages 40-41). 

For more information about Medigap protections, call 
1-800-MEDICARE (1-800-633-4227, TTY/TDD: 
1-877-486-2048 for the hearing and speech impaired) and 
ask for a free copy of Medigap Policies and Protections. 
You can also look on the Internet at www.medicare.gov 
to read or print this booklet. 



www.medicare.gov 59 



SECTION 6: QUESTIONS AND ANSWERS 



Q16: How do I get 

more information 
about Medigap 
policies? 



A: Call 1-800-MEDICARE (1-800-633-4227) and ask for a 
free copy of the 2000 Guide to Health Insurance for 
People with Medicare. Look at www.medicare.gov on 
the Internet to get information on Medigap policies in 
your state. Click on Medigap Compare. If you don't 
have a computer, your local library or senior center may 
be able to help you look at this information. 



Medicare managed care plan and Private Fee-for-Service plan 
Questions and Answers: 



Q17: How do I find out 
which plans are offered 
where I live, what they 
cost, and what extra 
benefits are covered? 



A: Call 1-800-MEDICARE (1-800-633-4227) and ask for a 
free, up-to-date list of all the plans offered where you 
live, with more detailed information comparing extra 
benefits and costs. 

OR 

Look at www.medicare.gov on the Internet. Click on 

Medicare Health Plan Compare. If you do not have a 
personal computer, your local library or senior center 
may be able to help you. 



Then call any plan you may be interested in. They can 
tell you if the plan is offered where you live and can 
send you up-to-date, detailed information about their 
extra benefits and costs. 



Q18: How do I find out 
if my doctor or hospital 
belongs to a plan? 



A: If you want to keep seeing your doctor when you join a 
plan, call and ask if he or she is in the plan and would 
continue to see you if you joined the plan. You can also 
get a list from your plan of doctors and hospitals that 
belong to the plan. 



60 



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SECTION 6: QUESTIONS AND ANSWERS 



Q19: How can I find out 
how the plan rates in 
quality (keeps its 
members healthy or 
treats them when they 
are sick), or how many 
people disenrolled 
(chose to leave their 
plan) and how many 
stayed? 

Q20: Who can help me 
compare plans? 



A: Call 1-800-MEDICARE (1-800-633-4227) and ask for 
quality and other information for the plans in your area. 

OR 
Look at www.medicare.gov on the Internet. Click on 
Medicare Health Plan Compare. If you do not have a 
personal computer, your local library or senior center 
may be able to help you. 



A: Call your State Health Insurance Assistance Program 
(see pages 26-27). Volunteer counselors can help you 
compare the Medicare health plans available to you. 



Q21: What can I do if 
my Medicare health 
plan does not stay in the 
Medicare program? 



A: If your Medicare health plan (like a Medicare managed 
care plan or Private Fee-for-Service plan) leaves the 
Medicare program, you will be sent a notice. The notice 
will tell you if there are other Medicare managed care 
plans or Private Fee-for-Service plans in your area that 
you can join. Or, you can always return to the Original 
Medicare Plan. You may be able to get a Medigap policy 
(see page 58). You should learn as much as you can 
about your choices before making a decision. No matter 
what you choose, you are still in the Medicare program 
and will get all Medicare-covered services. 



Q22: Why aren't 
Medicare managed care 
plans or Private Fee- 
for-Service plans 
available where I live? 



A: These Medicare health plans are offered by private 
companies. The companies decide which areas they will 
serve. Companies may decide to offer plans in your area in 
the future. For the most up-to-date information about 
Medicare health plans in your area, call 1-800-MEDICARE 
(1-800-633-4227, TTY/TDD: 1-877-486-2048 for the 
hearing and speech impaired) or look at www.medicare.gov 
on the Internet. 



www.medicare.gov 



61 



SECTION 6: QUESTIONS AND ANSWERS 



Q23: What is a "medical 
emergency"? How do I 
get emergency care? 



A: A medical emergency is when you believe that your 
health is in serious danger ~ when every second counts. 
You may have severe pain, a bad injury, sudden illness, 
or an illness quickly getting much worse. All Medicare 
managed care plans must allow you to get emergency 
care whenever you need it from any provider in the 
United States. You do not need permission from your 
primary care doctor first. Your plan must pay for 
emergency care. If you get a bill, give it to the plan to 
pay. If your plan does not pay for your emergency care, 
you have the right to appeal (see page 47). 



Q24:What is "urgently 
needed care"? How do 
get urgently needed 
care? 



A: Urgently needed care is care 
illness or injury that is not a 
Medicare managed care plan 
care from your primary care 
out of the plan's service area 
return home, your plan must 
care. If it does not, you have 
page 47). 



you need for a sudden 
medical emergency. In a 
, you get urgently needed 
doctor. However, if you are 
and cannot wait until you 
pay for urgently needed 
the right to appeal (see 



62 



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SECTION 6: QUESTIONS AND ANSWERS 



Special Care Questions and Answers: 



Q25: Does Medicare 
cover mental health 
care? 



A: If you are in the Original Medicare Plan, Part A covers 
inpatient mental health care, including room, meals, 
nursing, and other related services and supplies. Part B 
covers mental health services generally given outside a 
hospital, including visits with a doctor, clinical 
psychologist, clinical social worker, and lab tests (see 
page 8). For more information about Medicare coverage 
for mental health care, call 1-800-MEDICARE 
(1-800-633-4227) and ask for a free copy of Medicare 
and your Mental Health Benefits, or look at 
www.medicare.gov on the Internet. 

If you are in a Medicare managed care plan or a Private 
Fee-for-Service plan, read your plan materials or call the 
plan to learn about their coverage of mental health care. 
You must get at least the same coverage as provided by 
Part A and Part B of the Original Medicare Plan. 



Q26: Does Medicare 
pay for care in a nursing 
home? 



A: Usually, no. Most nursing home care is custodial care. 
This is different than what Medicare covers. Medicare 
Part A only covers skilled care given in a certified 
skilled nursing facility. You must meet certain conditions 
and coverage is limited (see page 6). 

Skilled care includes nursing or rehabilitation therapies 
given by skilled health care personnel such as registered 
nurses, licensed practical and vocational nurses, physical 
and occupational therapists, speech pathologists, and 
audiologists. 

For more information about Medicare's coverage of 
skilled care, call 1-800-MEDICARE (1-800-633-4227) 
and ask for a free copy of Medicare Coverage of Skilled 
Nursing Facility Care, or look at www.medicare.gov on 
the Internet. 



www.mcdicarc.gov 



63 



SECTION 6: QUESTIONS AND ANSWERS 



Q27: What is long-term 
care? 



A: Long-term care is different from traditional medical 
care. Someone with a physical illness, a disability, or a 
memory or thought problem (such as Alzheimer's 
disease) often needs long-term care. Long-term care is 
made up of many different services to help people with 
chronic conditions overcome limitations that keep them 
from being independent. Long-term care may include 
custodial care, which is help with activities of daily 
living (such as shopping, bathing, and dressing). Long- 
term care can also include home health care, respite 
care, adult day care, care in a nursing home, and care in 
an assisted living facility. Long-term care may also 
include special services that help coordinate and monitor 
your long-term care services. 



Q28: Does Medicare 
pay for long-term care? 



A: No. Generally, Medicare only covers care that is both 
medically necessary and covered under Part A (hospital 
insurance) and Part B (medical insurance). You must 
meet certain conditions for Medicare to cover skilled 
nursing facility, home health, and hospice care. 
Medicare does not cover custodial care. 



Q29: What is long-term 
care insurance? 



A: Long-term care insurance is one way you may pay for 
long-term care. This type of insurance will pay for some 
or all of your long-term care. Long-term care insurance 
is relatively new. It was introduced in the 1980s as 
nursing home insurance, but it has changed a lot and 
now covers much more than nursing home care. 

For more information about long-term care insurance, 
get a copy of A Shopper's Guide to Long-Term Care 
Insurance from your State Insurance Department, or 
write to the National Association of Insurance 
Commissioners, 120 W. 12th Street, Suite 1 100, Kansas 
City, MO 64105-1925. 



64 



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SECTION 6: QUESTIONS AND ANSWERS 



Q30: How can I find out A: You can get important information on the Internet at 
about the nursing homes www.medicare.gov about the nursing homes in your 

in my area? area. Click on Nursing Home Compare for information 

and nursing home inspection reports for all the Medicare 
and Medicaid-certified nursing homes in the country. If 
you don't have a computer, your local library or senior 
center may be able to help you look at this information. 
You can also call 1-800-MEDIC ARE (1-800-633-4227, 
TTY/TDD: 1-877-486-2048 for the hearing and speech 
impaired) and ask for a free copy of Your Guide to 
Choosing a Nursing Home. 



www.medicare.gov 65 



SECTION 7: FOR MORE INFORMATION 

Free Medicare and Related Booklets 




How do I get these 
booklets? 



What booklets are 
available? 



Medicare has many booklets to help you learn about the 
program. This handbook contains basic information that 
everyone with Medicare needs to know. Other booklets can 
give you more details about topics that are of interest to you. 
Medicare will continue to add new booklets to get you the 
information you need. 

You can: 

1. Call 1 -800-MEDIC ARE (1-800-633-4227, TTY/TDD: 
1-877-486-2048 for the hearing and speech impaired) and 
ask for a free copy of the booklet you want. 

2. Look on the Internet at www.medicare.gov and click on 
Publications. You can read or print out these booklets. 

About Basic Medicare Information: 

• Medicare & You 2001 

You can get free copies of this handbook in: 

• English print (like this one) 

• Spanish print 

• English large print 

• Spanish large print 

• English audiotape 

• Spanish audiotape 

• Braille 

About Services Medicare Covers: 

• Medicare and Your Mental Health Benefits New! 

• Medicare Coverage of Kidney Dialysis and Kidney 
Transplant Services New! 

• Medicare Coverage of Skilled Nursing Facility Care New! 

• Medicare Coverage For Second Surgical Opinion 

• Medicare Home Health Care Services 

• Medicare Hospice Benefits 

• Medicare Preventive Services 



66 



1-800-MEDICARE (1-800-633-4227) 



SECTION 7: FOR MORE INFORMATION 



What booklets are 

available? 

(continued) 



About Health Care Choices: 

• Choosing a Doctor New! 

• Choosing a Hospital New! 

• Choosing Treatments New! 

• Your Guide to Choosing a Nursing Home 

• Private Contracts Fact Sheet 

• Nursing Homes Fact Sheet 

About Medicare Health Plan Choices and 
Supplemental Coverage: 

• Health Plan Comparison Information (with quality data) 

• Learning about Medicare Health Plans 

• 2000 Guide to Health Insurance for People with 
Medicare 

• Your Guide to Private Fee-for-Service Plans 

• Your Guide to Medicare Medical Savings Accounts 

• Worksheet for Comparing Medicare Health Plans 

About Your Rights and Protections: 

• Medicare Appeals and Grievances (Complaints) 

• Medicare Fraud and Abuse 

• Medicare Patient Rights 

• Medigap Policies and Protections 

About Costs and Payment: 

• Do You Need Help to Pay Health Care Costs? 

• Does Your Doctor or Supplier Accept Assignment? 

• Medicare and Other Health Benefits: Your Guide to Who 
Pays First New! 

• Your Guide to the Outpatient Prospective Payment 
System New! 

Note: Many of these booklets are available in Audiotape 
(English and Spanish), Braille, Large Print, and Spanish. 
Some booklets are also available in Chinese. 



vvww.medicare.gov 



67 



SECTION 7: FOR MORE INFORMATION 

Call 1-800-MEDICARE (1-800-633-4227, TTY/TDD: 1-877-486-2048) to: 

• Get more help with your Medicare questions. 

• Order quality and other information about the Medicare health plans in your area. 

• Listen to recorded questions and answers on topics such as Medicare health plan choices. 

• Order Medicare publications. (Some are available in Audiotape, Braille, Large print, and 
Spanish.) 



To replace your 

Medicare card or 

change your 

address. 



Press or 

say one 

(1) 



Call 1-800-MEDICARE (1-800-633-4227) 
| Listen to the options carefully, as they may change. 



To listen in English, press or say one (1) 
To listen in Spanish, press or say two (2) 



To order publications or to 
hear pre-recorded answers 

to frequently asked 
Medicare questions, or for 

information about a 
Medicare claim. 



For information on 

help in paying your 

medical bills. 



I Press or j 

I say two I 

(2) 



To speak with a 

Customer Service 

Representative. 



; Press or j 


Press or 


isay three! 


say zero 


(3) 


(0) 



Important Notes About 1-800-MEDICARE 

• If you are hearing or speech impaired, call the TTY/TDD line toll-free at 1-877-486-2048 for these 
options. 

• Once you have called 1-800-MEDICARE, you can either press the numbers listed or just say 
the numbers to request what you want. 

• You can hear a recording with answers to frequently asked questions, and can order 
publications 24 hours a day, 7 days a week. 

• You can talk with a Customer Service Representative between 8:00 a.m. and 4:30 p.m. in 
your time zone, Monday through Friday. 

68 1-800-MEDICARE (1-800-633-4227) 



SECTION 8: DEFINITIONS OF IMPORTANT TERMS 



Appeal - An appeal is a special kind of 
complaint you make if you disagree with any 
decision about your health care services. For 
example, if Medicare doesn't pay for a service 
you got. This complaint is made to your 
Medicare health plan or the Original Medicare 
Plan. There is usually a special process you 
must use to make your complaint. 

Benefit Period - The way that Medicare 
measures your use of hospital and skilled 
nursing facility services. A benefit period 
begins the day you go to a hospital or skilled 
nursing facility. The benefit period ends when 
you have not received hospital or skilled 
nursing care for 60 days in a row. If you go 
into the hospital after one benefit period has 
ended, a new benefit period begins. You must 
pay the inpatient hospital deductible for each 
benefit period. There is no limit to the number 
of benefit periods you can have. 

Coinsurance -The percent of the Medicare- 
approved amount that you have to pay after 
you pay the deductible for Part A and/or 
Part B. In the Original Medicare Plan, the 
coinsurance payment is a percentage of the 
cost of the service (like 20%). 

Copayment - In some Medicare health plans, 
the amount that you pay for each medical 
service you get, like a doctor visit. A 
copayment is usually a set amount you pay for 
a service. For example, this could be $5 or 
$10 for a doctor visit. Copayments are also 
used for some hospital outpatient services in 
the Original Medicare Plan. 



Deductible - The amount you must pay for 
health care, before Medicare begins to pay, 
either each benefit period for Part A, or each 
year for Part B. These amounts can change 
every year. 

End-Stage Renal Disease - Kidney failure 
that is severe enough to require lifetime 
dialysis or a kidney transplant. 

General Enrollment Period (GEP) - The 

GEP is January 1 through March 31 of each 
year. If you enroll in Part B or Part A (if you 
don't get it automatically without paying a 
premium) during the GEP, your coverage starts 
on July 1 . 

Grievance - A complaint about the way your 
Medicare health plan is giving care. For 
example, you may file a grievance if you have 
problems with the cleanliness of the health 
care facility, calling the plan, staff behavior, or 
operating hours. A grievance is not the same 
as an appeal, which is the way to deal with a 
complaint about a treatment decision or a 
service that is not covered (see Appeal). 

Inpatient Care - Health care that you get 
when you stay overnight in a hospital. 

Limiting Charge -The highest amount of 
money you can be charged for a covered 
service by doctors and other health care 
providers who don't accept assignment. The 
limit is 1 5% over Medicare's approved 
amount. The limiting charge only applies to 
certain services and does not apply to supplies 
or equipment. 



www.medicare.gov 



69 



SECTION 8: DEFINITIONS OF IMPORTANT TERMS 



Medicaid - A joint Federal and State program 
that helps with medical costs for some people 
with low incomes and limited resources. 
Medicaid programs vary from state to state, 
but most health care costs are covered if you 
qualify for both Medicare and Medicaid. 

Medically Necessary - Services or supplies 
that: 

• are proper and needed for the diagnosis or 
treatment of your medical condition; 

• are provided for the diagnosis, direct care, 
and treatment of your medical condition; 

• meet the standards of good medical practice 
in the medical community of your local area; 
and 

• are not mainly for the convenience of you or 
your doctor. 

Medicare-Approved Amount - The fee 
Medicare sets as reasonable for a covered 
medical service. This is the amount a doctor 
or supplier is paid by you and Medicare for a 
service or supply. It may be less than the 
actual amount charged by a doctor or supplier. 
The approved amount is sometimes called the 
"Approved Charge." 

Medicare Managed Care Plan - These are 
health care choices in some areas of the 
country. In most plans, you can only go to 
doctors, specialists, or hospitals on the plan's 
list. Plans must cover all Medicare Part A and 
Part B health care. Some plans cover extras, 
like prescription drugs. Your costs may be 
lower than in the Original Medicare Plan. 



70 



1-800-MEDICARE 



Medicare Medical Savings Account (MSA) - 

A Medicare health plan option made up of 
two parts. One part is a Medicare MSA 
Health Insurance Policy with a high 
deductible. The other part is a special savings 
account where Medicare deposits money to 
help you pay your medical bills. 

Medigap - A Medicare supplemental health 
insurance policy sold by private insurance 
companies to fill "gaps" in Original Medicare 
Plan coverage. Except in Massachusetts, 
Minnesota, and Wisconsin, there are 10 
standardized policies labeled Plan A through 
Plan J. Medigap policies only work with the 
Original Medicare Plan. 

Peer Review Organization (PRO) - Groups 
of practicing doctors and other health care 
experts paid by the Federal Government to 
monitor and improve the care given to 
Medicare patients. They must review your 
complaints about the quality of care provided 
by inpatient hospitals, hospital outpatient 
departments, hospital emergency rooms, 
skilled nursing facilities, home health 
agencies, Medicare managed care plans, and 
ambulatory surgical centers. 

Premium - What you pay monthly for health 
care coverage to Medicare, an insurance 
company, or a health care plan. 

Primary Care Doctor - A doctor who is 
trained to give you basic care. This includes 
being the first one to check on health 
problems and coordinating your preventive 
health care with other doctors, specialists, and 
therapists. In many Medicare managed care 
plans, you must see your primary care doctor 
before you can see any other health care 
provider. (See Medicare Managed Care Plan.) 
(1-800-633-4227) 



SECTION 8: DEFINITIONS OF IMPORTANT TERMS 



Private Fee-for-Service Plan - A private 
insurance plan that accepts Medicare 
beneficiaries. You may go to any doctor or 
hospital you want. The insurance plan, rather 
than the Medicare program, decides how 
much it will pay and what you pay for the 
services you get. You may pay more for 
Medicare-covered benefits. You may have 
extra benefits the Original Medicare Plan 
does not cover. 

Quality - Quality is how well the health plan 
keeps its members healthy or treats them 
when they are sick. Good quality health care 
means doing the right thing at the right time, 
in the right way, for the right person—and 
getting the best possible results. 

Referral - An OK from your primary care 
doctor for you to see a specialist or get certain 
services. In many Medicare managed care 
plans, you need to get a referral before you 
can get care from anyone except your primary 
care doctor. If you do not get a referral first, 
the plan may not pay for your care. 

Reserve Days - Sixty days that Medicare will 
pay for when you are put in a hospital for 
more than 90 days. These 60 reserve days can 
be used only once during your lifetime. For 
each lifetime reserve day, Medicare pays all 
covered costs except for a daily coinsurance 
amount ($388 in 2000). 

Skilled Nursing Facility Care* - A level of 
care that must be given or managed by 
licensed health care professionals and is under 
the general direction of a doctor. All of your 
needs are taken care of with this type of 
service, including getting direct services. As 



long as you need skilled care, it makes no 
difference whether your illness is acute, 
chronic, or terminal. Medicare does not cover 
unskilled (custodial) care, except when it is 
given in addition to Medicare-covered skilled 
care. 

Special Enrollment Period (SEP) - A set 

time when you can sign up for Medicare Part 
B if you did not take Part B during the Initial 
Enrollment Period, because you or your 
spouse currently work and have group health 
plan coverage through the employer or union. 
You can sign up at any time you are covered 
under the group plan. If the employment or 
group health coverage ends, you have 8 
months to sign up. The 8-month SEP starts 
the month after the employment ends or the 
group health coverage ends, whichever comes 
first. 

State Health Insurance Assistance Program 

(SHIP) - A state organization that gets money 
from the Federal Government to give free 
health insurance counseling and assistance to 
people with Medicare. 



* This definition in whole or in part was used 
with permission from Walter Feldesman, Esq., 
Dictionary of Eldercare Terminology 2000. 



www.medicare.gov 



71 



SECTION 9: INDEX 



Page(s) 

1-800-MEDICARE Helpline 24, 68 

Advance Beneficiary Notice (ABN) 47 

Ambulance Services 10 

Approved Amount 6, 8, 9, 70 

Artificial Limbs and Eyes 10 

Assignment 56 

Benefit Period 6, 69 

Bills (Claims) 

Part A 56 

Part B 56 

Blood 6,8 

Bone Mass Measurement 9 

Booklets/Pamphlets for More 

Information 66-67 

Braces (arm, leg, back, and neck) 10 

Cataract Surgery 10 

Children's Health Insurance Program 11 



Page(s) 

Deductible 8, 9, 69 

Definitions 69-71 

Dental Care 10 

Diabetes 9 

Discrimination 48 

Disenrollment (Plan) 20 

Durable Medical Equipment (like 

wheelchairs) 6, 28 

Emergency Care 10, 45, 62 

Employer Health Coverage 12, 22 

End-Stage Renal 

Disease (ESRD) 4, 17, 57, 69 

Enrollment 

Part A 5 

PartB 7,53 

Explanation of Medicare Benefits Notice ..47 
Eye Care 10 



Chiropractic Services 10 Fiscal Intermediary 29A-31 

Choices (Health Plan) 13 Flu Shot 9 

Civil Service Retirement 7 Fraud and Abuse 50-51 

Clinical Laboratory Service 8 General Enrollment Period 53, 69 

Clinical Psychologist Services 63 Grievance (Complaint) 46, 69 



Coinsurance 9, 14, 52, 69 

Colonoscopy 9 

Colorectal Cancer Screening 9 

Complaint (Grievances) 46 

Copayment 6, 69 

Costs 5-11 



Health Plan (Also see Original Medicare 
Plan, Medicare Managed Care 
Plan, and Private Fee-for-Service 
Plan.) 
Choice 13-22 

Hearing Aids 10 



Assignment 56 Hepatitis B Shot 9 

Coinsurance 9, 14, 52, 69 Home Health Care 5-8, 49 

Copayment 6, 8, 1 1, 69 Hospice Care 5, 6 



Deductible 8, 9, 69 

Help with Costs 11 

Limiting Charge 55, 69 

Medicare Managed Care Plan 18 

Original Medicare Plan 14-15 

Out-of-Pocket Costs 6-10, 12, 13 

Private Fee-for-Service Plan 18 



Hospital (care, inpatient coverage, patient 

rights) 5, 6, 48 

Immunosuppressive Drug Therapy 10 

Kidney Dialysis (transplants) 10 

Long-Term Care 26, 27, 64 

Mammogram 9 

Medicaid 11, 54, 70 



Covered Services (Part A and B) 5-10 Medically Necessary 6, 70 

Custodial Care 10, 64 Medicare Appeal 45, 46-47, 69 



72 



1-800-MEDICARE (1-800-633-4227) "U.S. Government Printing Office: 2000-462-015/20007 



SECTION 9: INDEX 

Page(s) 



Page(s) 



Medicare Card 5 

Getting a new card 52 

Medicare Carrier 25A-E 

Medicare + Choice 13 

Medicare Managed Care Plans 16-22, 70 

Costs 18 

Disenrollment (Leaving) 20 

Enrollment (Joining) 17-19 

If plan leaves Medicare 21, 61 

Medicare Medical Savings Accounts ....22, 70 
Medicare Part A and Part B (see Part A, 

or Part B) 5-10,53 

Medicare SELECT 59 

Medicare Secondary Payer 54 

Medicare Summary Notice 47 

Medigap 15, 21, 57-60, 70 

Mental Health Care 63 



Private Fee-for-Service Plans 17-21, 71 

Costs 18 

Disenrollment (Leaving) 20 

Joining 17-19 

If plan leaves Medicare 21, 61 

Prostate (Screening, PSA Test) 9 

Prosthetic Devices 10 

Protections 45-51 

Psychiatric Facility 6 

Qualified Medicare Beneficiary (QMB) ....11 

Qualifying Individual 11 

Quality (Health Plan) 22, 71 

Questions and Answers 52-65 

Railroad Retirement Board 1, 24 

Referral 16,71 

Regional Home Health Intermediary ....32, 33 
Reserve Days 6, 71 



Military Retiree 12 Respite Care 6 

Nursing Homes 63, 65 Rights 45-51 

Occupational Therapy 6, 7 Service Area 17 

Office for Civil Rights 44 Shots (Vaccinations) 9, 10 

Original Medicare Plan 14-15 Skilled Nursing Facility 

Costs 14-15 (SNF) Care 5, 6, 49, 71 

Outpatient Hospital Services 7, 8 Social Security Administration 24 

Program of All-Inclusive Care for the Elderly Special Enrollment Period 53, 71 

(PACE) 59 Specialist 14, 16 

Pap Smear 9 Specified Low-Income Medicare Beneficiary 

Part A (Hospital Insurance) 5, 6, 10 (SLMB) 11 



Part B (Medical Insurance) 7-10, 53 

Peer Review Organization 34-39 

Phone Numbers for Help 23-44 

Physical Exams 10 

Physical Therapy 6-8 

Pneumonia Shot 9 

Point-of- Service Option 16 

Premium 5, 7, 10, 52, 70 

Prescription Drugs 10, 54 

Preventive Services 9, 10 

Primary Care Doctor 16, 70 

Private Contract 55 



Speech-Language Therapy 6 

State Health Insurance 

Assistance Program 26, 27, 71 

Supplement Insurance Policies 

(Medigap) 15, 21, 57-60, 70 

Transplants 10 

Travel 10,54 

Union Health Coverage 12, 22 

U. S . Department of Veteran Affairs 12 

Urgently Needed Care 62 

Veterans 12, 24 

X-rays 10 

www.medicare.gov 73 



U.S. DEPARTMENT OF 

HEALTH AND HUMAN SERVICES 

HEALTH CARE FINANCING ADMINISTRATION 

7500 Security Boulevard 
Baltimore, Maryland 21244-1850 

Official Business 

Penalty for Private Use, $300 

Publication No. HCFA- 10050 
September 2000 



CNS LIBRARY 



\ 



3 6DTS DDOlOflBb t, 



National Medicare Handbook; with a listing of important phone numbers for your area. 



To get this handbook on 
Audiotape, Braille, 
Large Print, or Spanish, 
call 1-800-633-4227, 
TTY/TDD: 1-877-486- 
2048 for the hearing 
and speech impaired. 



MEDICARE • MEDICAID 

Health Care Financing Administration 



Call 1-800-MEDICARE 
(1-800-633-4227) or look on the Internet 
at www.medicare.gov to get help with 
your Medicare questions. 

^Necesita listed una copia en Espaiiol? 
Por favor llame gratis al 1-800-633- 
4227, TTY/TDD: 1-877-486-2048 para 
personas con impedimento auditivo o^ 
de lenguaje oral.